(PMI) Is a Historic Tremendous Burden on National Health Systems and $1.2 Billion, Five-Year Expansion of U.S

THE PRESIDENT’S MALARIA INITIATIVE WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA THIRD ANNUAL REPORT MARCH 2009 THE PRESIDENT’S MALARIA INITIATIVE WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA

THIRD ANNUAL REPORT MARCH 2009 Cover photo The President’s Malaria Initiative strives to reduce the burden of malaria across Africa by targeting the two most vulnerable groups — pregnant women and children under five, such as these children at a health clinic in Kenya.

Credit Bonnie Gillespie/Voices for a Malaria-Free Future

ii WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov TABLE OF CONTENTS

Abbreviations and Acronyms ...... v

Executive Summary ...... 1

Chapter 1 The Challenge of Malaria Control ...... 9

Chapter 2 Progress to Date in PMI Round 1 Countries: Angola, Tanzania, and Uganda ...... 15

Chapter 3 Progress to Date in PMI Round 2 Countries: Malawi, Mozambique, Rwanda, and Senegal ...... 27

Chapter 4 Benin ...... 41

Chapter 5 Ethiopia: Oromia Region ...... 47

Chapter 6 Ghana ...... 51

Chapter 7 Kenya ...... 55

Chapter 8 Liberia ...... 59

Chapter 9 Madagascar ...... 63

Chapter 10 Mali ...... 69

Chapter 11 Zambia ...... 73

Chapter 12 Supporting Interventions at the Community Level ...... 79

Chapter 13 Progress Through Partnerships ...... 83

Chapter 14 Building Health Systems and National Capacity ...... 87

Appendix 1 Baseline and Interim Coverage of Malaria Interventions in PMI Focus Countries ...... 91

Appendix 2 PMI Country-Level Targets ...... 94

Appendix 3 Summary of Results by Intervention ...... 95

Acknowledgments ...... 99

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov iii iv WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov ABBREVIATIONS AND ACRONYMS

ACT Artemisinin-based combination therapy AL Artemether-lumefantrine ANC Antenatal clinic BCC Behavior change communication CBO Community-based organization CDC Centers for Disease Control and Prevention CHW Community health worker DHS Demographic and Health Survey EPI Expanded Program on Immunization FANC Focused antenatal care FBO Faith-based organization FY Fiscal year Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome IEC Information, education, and communication IPTp Intermittent preventive treatment for pregnant women IRS Indoor residual spraying ITN Insecticide-treated net MOH Ministry of Health NGO Nongovernmental organization NMCP National Malaria Control Program PEPFAR U.S. President’s Emergency Plan for AIDS Relief RDT Rapid diagnostic test

SP Sulfadoxine-pyrimethamine UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development WHO World Health Organization

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov v THE PRESIDENT’S MALARIA INITIATIVE

“Experience shows that when partners work together, and when malaria control strategies – such as nets, effective medicines, indoor spraying – are employed comprehensively and on a mass scale, extraordinary success can be realized.” – Professor Awa-Marie Coll-Seck, Executive Director of the Roll Back Malaria Partnership, February 8, 2008

BONNIE GILLESPIE/ A community health worker reviews malaria education materials with a young mother in Uganda. PMI VOICES FOR A MALARIA-FREE FUTURE works with National Malaria Control Programs to increase attendance at antenatal and child health clinics through health promotion and education activities.

1 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov EXECUTIVE SUMMARY

Malaria is a preventable and treatable disease. It remains greatest burden of malaria usually falls on residents of one of the major causes of illness and death among rural areas, where access to health care is limited by cost children in Africa, and is estimated to account for 300 or distance. As a result, the control of malaria is a major million to 500 million illnesses and nearly 1 million objective of the U.S. foreign assistance program. deaths each year, with 90 percent of those deaths in children under five years of age. Malaria also places a The President’s Malaria Initiative (PMI) is a historic tremendous burden on national health systems and $1.2 billion, five-year expansion of U.S. Government individual families. Economists estimate that malaria (USG) resources to reduce the intolerable burden of accounts for approximately 40 percent of public health malaria and help relieve poverty on the African conti- expenditures in Africa and causes an annual loss of $12 nent. The goal of PMI is to reduce malaria-related billion, or 1.3 percent of the continent’s gross domestic deaths by 50 percent in 15 countries with a high burden product. Malaria and poverty are closely linked; the of malaria by expanding coverage of four highly effective

PMI RESULTS AT A GLANCE1 PMI Year 1 PMI Year 2 PMI Year 3 Cumulative Results (2006) (2007) (2008) Number of people protected by PMI is supporting IRS in 14 2,097,056 18,827,709 24,787,363 indoor residual spraying countries2 12,739,652 Number of ITNs procured 1,047,393 5,210,432 6,481,827 (8,978,369 distributed) Number of ITNs procured by other partners and distributed 0 369,900 1,287,624 1,657,524 with PMI support Number of mosquito nets 505,573 802,740 581,319 1,889,632 re-treated Number of ACT treatments 28,394,852 1,229,550 11,537,433 15,627,869 procured (18,139,983 distributed3) Number of ACT treatments procured by other partners and 0 8,709,140 112,330 8,821,470 distributed with PMI support Number of health workers 8,344 20,864 35,397 N/A4 trained in use of ACTs Number of rapid diagnostic 5,137,475 1,004,875 2,082,600 2,050,000 tests procured (3,459,475 distributed3) Number of IPTp treatments 2,368,332 0 1,349,999 1,018,333 procured5 (585,889 distributed3) Number of health workers 1,994 3,153 14,194 N/A4 trained in IPTp

1 Results reported in this table are up-to-date as of January 1, 2009, and include all 15 PMI focus countries. 2 A cumulative total of people protected by indoor residual spraying cannot be calculated without double counting. 3 Distributed to health facilities. 4 A cumulative total of health workers trained cannot be calculated without double counting. 5 A treatment of IPTp consists of three tablets of sulfadoxine-pyrimethamine.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 2 malaria prevention and treatment measures to 85 percent of the most vulnerable populations – pregnant women and children under five years of age.

Progress under PMI in scaling up malaria prevention and control interventions during the last 36 months has been OSHARE dramatic. The belief that malaria in sub-Saharan Africa really can be controlled is already being substantiated

with clear evidence of reductions in malaria burden in TESY OF PHOT

many of the PMI focus countries. A/COUR OFUEKWAT GILBER OFUEKWAT PMI Operating Principles Malaria is a health emergency in Africa, and PMI, together with its partners, is moving quickly and effec- Children in the Adit Internally Displaced Persons Camp in tively to scale up interventions, build local capacities, northern Uganda lie under a mosquito net in preparation for and strengthen maternal and child health systems to bedtime. PMI works with its partners to provide free nets to camp residents to protect them from malaria, one of the leading facilitate expansion of programs nationwide. PMI’s killers of young children in these camps. management plan stresses:

• Minimizing lead times for procurement of critical thousands of health workers and community volunteers. commodities and services; Finally, PMI promoted increased understanding and demand for malaria prevention and treatment interven- • Flexibility in working with other donors to fill gaps tions by funding a wide range of behavior change in core malaria commodities and services, such as PMI communication and education activities across the 15 funding the distribution of insecticide-treated nets focus countries. (ITNs) procured by other partners; and Working with national governments and other donors, • Maintaining a PMI Central Emergency Procurement PMI has helped to rapidly scale up malaria prevention Fund to help ensure that no PMI focus country and treatment measures. As a result, an impact on malaria experiences a stockout of essential commodities (Page 7). transmission is already being seen:

Achieving Results • In Zambia, 2006 and 2008 nationwide Malaria In the third year of the Initiative, PMI-supported malaria Indicator Surveys show that malaria control efforts prevention and treatment measures were expanded across led by a strong National Malaria Control Program all 15 focus countries. PMI procured more than 6.4 mil- (NMCP) and supported by PMI, the Global Fund, lion long-lasting ITNs, most of which have been or will the Bill and Melinda Gates Foundation, the World be distributed free of charge to pregnant women and Bank, and other partners are having a dramatic impact young children. Indoor residual spraying (IRS) activities on the prevalence (frequency) of malaria and anemia. were also expanded, and a total of 6 million houses were Over this three-year period, the prevalence of malaria sprayed with synthetic pyrethroids, carbamates, or DDT, fell by 53 percent, and the prevalence of severe anemia helping to protect more than 24.7 million people at risk in children under five years of age, which is closely of malaria. During 2008, 15.6 million artemisinin-based associated with malaria, fell by 68 percent (Figure 1). combination therapies (ACTs) were procured in nine In addition, a 2007 nationwide survey showed a 29 focus countries for the treatment of acute malarial illnesses. percent reduction in all-cause mortality in children PMI also supported the expansion of intermittent pre- under five, to which malaria is a major contributor ventive treatment for pregnant women (IPTp) as part (Box 1). The USG has been supporting the Zambian of broader efforts to improve and expand antenatal care national malaria program since 2002, including $7.6 services. To build capacity and promote sustainability, million in FY 2006 and $9 million in PMI jump start PMI also helped strengthen pharmaceutical manage- funding in FY 2007. ment, quality assurance of drugs, and health management information systems and trained tens of

3 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov • In Rwanda, support by PMI, the Global Fund, and increased ITN ownership and use, together with targeted other donors for a strong malaria control effort, led by IRS and the rollout of ACTs at both the community the NMCP, is producing striking reductions in the and health facility levels, was associated with a fall in malaria burden. Preliminary results of a 2008 interim the prevalence of malaria to less than 3 percent and an nationwide Demographic and Health Survey (DHS) overall reduction in under five childhood mortality of show about a fourfold increase in ownership of one or 32 percent between 2005 and 2008 (from 152 to 103 more ITNs, from 13 to 57 percent, and in the pro- deaths per 1,000 live births) (Box 1). The USG has portion of children under five sleeping under an ITN, been supporting malaria control efforts in Rwanda from 15 to 58 percent between 2005 and 2008. This since 2002, including $1.5 million in PMI jump start funding in FY 2006 and $20 million in FY 2007.

FIGURE 1 • In Zanzibar, following a rapid scale-up of ITNs, IRS, Decline in Malaria Prevalence and Severe and ACTs between 2005 and 2007 (supported by PMI, Anemia in Children Under Five Years of Age, the Global Fund, and other partners), the proportion Zambia, 2006–2008 of blood smears positive for malaria in children under two years of age attending health clinics fell from 22 percent to less than 1 percent. This low level of blood smear positivity was sustained during 2008. Focus has now turned to strengthening malaria case surveillance to allow rapid detection and response to any potential resurgence of malaria cases.

• In Tanzania, during 2008, PMI continued to support IRS in Muleba District, consolidating the gains in malaria control seen during the previous year. A further drop of 55 percent in blood smears positive for malaria in patients of all ages was observed during 2008. In total, between 2006 and 2008, the prevalence of malaria during the peak transmission period of June–July fell by 73 percent (Figure 2).

FIGURE 2 Decline in Proportion of Blood Smears Positive for Malaria, Muleba District Hospital, Tanzania, 2006–2008

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 4 • In Malawi, household surveys conducted in 2007 and targeted for long-lasting ITN distribution. An inde- 2008 in Nkhotakota District demonstrate a relative pendent survey (funded by the Bill and Melinda Gates reduction of 28 percent in severe anemia in children 6 Foundation through the Innovative Vector Control months to 30 months of age. A closer look at areas Consortium) was conducted in November 2008 in the within the district where PMI supported IRS in same six districts. Results showed a 38 percent decline October–November 2007 shows an even greater reduc- in malaria prevalence when compared to a similar tion of 44 percent in severe anemia. In light of these 2007 survey. positive results, the Malawi Ministry of Health (MOH) plans to scale up IRS in six additional high-risk districts. PMI – A Partner in Malaria Control Partnerships at both the international and national levels • In Mozambique, in 2007, at the request of the NMCP, are key to PMI’s strategy and success. PMI coordinates PMI helped expand and strengthen the government’s its activities with major multilateral and bilateral institu- IRS program in Zambézia Province. With PMI sup- tions and donors, such as the World Health Organization port, a total of 586,568 houses were sprayed, and (WHO), UNICEF, the World Bank, the Global Fund, more than 2.5 million people were protected. Between the U.K. Department for International Development, September and November 2008, PMI supported a and the Bill and Melinda Gates Foundation. During the second round of IRS, during which 412,923 houses past year, PMI expanded collaboration with the private were sprayed and more than 1.4 million people were sector, nongovernmental organizations (NGOs), and protected. Fewer houses were sprayed in the second faith-based organizations (FBOs). These groups often round because houses that were harder to reach were have strong bases of operation in underserved rural areas, where the burden of malaria is greatest. The Malaria Communities Program, launched in December 2006, catalyzes partnerships with small national and interna- BOX 1 tional NGOs and FBOs. In Year 3, through the Malaria Scale-Up of Malaria Prevention and Treatment Measures Associated With Communities Program alone, PMI provided more than Reduction in Under-Five Mortality $11 million in grants to eight NGOs and FBOs working at the community level in PMI focus countries. In total, PMI has supported more than 150 nonprofit organizations, more than 40 of which are faith based.

In 2007 and 2008, PMI, the ExxonMobil Foundation, Malaria No More, and many others contributed funding to the Harmonization Working Group of the Roll Back Malaria Partnership to improve the success rate of African countries applying for Global Fund malaria grants. This support has had a major impact. In the most recent round (Round 8), 78 percent of the 18 African countries that received technical support from the Harmonization Working Group were successful in their grant applications. The increased funds will greatly contribute to the rapid scale-up of malaria prevention and treatment interventions in PMI focus countries and other high-burden African countries. Malaria prevention and treatment measures are associated with and can contribute to r eductions in PMI continues to work with WHO and other technical under-five childhood mortality. This is already being seen in Zambia and Rwanda, where, according to suc- partners to reach consensus on issues, such as how best cessive DHS surveys, under-five mortality rates are to use microscopic diagnosis and rapid diagnostic tests in dropping in association with scaled-up prevention and different epidemiological and clinical settings; how to treatment interventions and reductions in the preva- improve quality standards for antimalarial drugs, especially lence of malaria infections. ACTs; and how to roll out community-based treatment of malaria with ACTs.

5 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov PMI BACKGROUND

PMI Structure: PMI is an interagency initiative led by the U.S. Agency for International Development (USAID) and implemented together with the Centers for Disease Control and Prevention (CDC) of the Depar tment of Health and Human Services (HHS). It is overseen by the U.S. Global Malaria Coordinator, advised by an Interagency Steering Group made up of representatives of USAID, CDC/HHS, Department of State, Department of Defense, National Security Council, and Office of Management and Budget. PMI Country Selection: The 15 focus countries were selected and approved by the Malaria Coordinator and the Interagency Steering Group using the following criteria: • High malaria disease burden; • National malaria control policies consistent with the internationally accepted standards of the WHO; • Capacity to implement such policies; • Willingness to partner with the United States to fight malaria; and • Involvement of other international donors and par tners in national malaria control efforts.

PMI Approach: PMI is organized around four operational principles based on lessons learned fr om more than 50 years of USG efforts in fighting malaria, together with experience gained from implementation of PEPFAR, which began in 2003. The PMI approach involves: • Use of a comprehensive, integrated package of proven prevention and treatment interventions; • Strengthening of health systems and integrated maternal and child health ser vices; • Commitment to strengthen NMCPs and to build capacity for country ownership of malaria control efforts; and • Close coordination with international and in-countr y partners.

PMI works within the overall strategy and plan of the host countr y’s NMCP, and planning and implementation of PMI activities are coordinated closely with each MOH.

PMI FUNDING SUMMARY

Fiscal Year (FY) Budget Focus Countries

2006 $30 million1 Angola, Tanzania, and Uganda

2007 $135 million2 Malawi, Mozambique, Rwanda, and Senegal (in addition to Round 1 countries)

Benin, Ethiopia (Oromia Region), Ghana, Kenya, Liberia, Madagascar, Mali, 2008 $300 million3 and Zambia (in addition to Round 1 and Round 2 countries)

2009 $300 million All 15 PMI focus countries

2010 $500 million All 15 PMI focus countries

TOTAL: $1.265 billion

1 In addition, Angola, Tanzania, and Uganda also used $4.2 million in FY05 funds for malaria activities. 2 This total does not include $25 million of additional FY07 funding, of which $22 million was used for malaria activities in the 15 PMI focus countries. In addition, Malawi, Mozambique, Rwanda, and Senegal used $11.9 million in FY06 funds for malaria activities as allocated by the Malaria Coordinator. 3 Benin, Ethiopia (Oromia Region), Ghana, Kenya, Liberia, Madagascar, Mali, and Zambia also used $23.6 million of FY06 funding and $42.8 million of FY07 funding (of which $2.8 million was included in the $25 million additional FY07 funding) as allocated by the Malaria Coordinator.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 6 PMI Drug and Commodity Security: Central Emergency Procurement Fund

For malaria case management and prevention, maintaining adequate drug and commodity supplies can be a matter of life and death. Stockouts of critical malaria treatments, such as ACTs, can result in increases in morbidity and mortality. Similarly, stockouts of mosquito nets and indoor insecticide spray have been associated with increases in malaria cases, particularly in children and infants. PMI works with partner countries to prevent such shortages by ensuring adequate stocks of malaria drugs and other commodities. This effort culminated in the creation of the PMI Central Emergency Procurement Fund. If a country needs drugs or commodities but lacks funds to mak e the purchase, the Central Fund buys and ships the necessar y goods. In 2008, use of the Central Fund a verted what could have been disastrous stockouts in Liberia and

Malawi. In both countries, funding from other donors POLINA FLAHIVE/JSI arrived later than expected, leaving the countries without Dr. Bernice Dahn, Deputy Minister and Chief Medical sufficient funds to purchase ACTs. In Kenya, a stockout Officer at the Ministry of Health and Social Welfare in had already occurred and was mitigated by the Central Liberia, accepts PMI’s emergency shipment of 496,000 ACT Fund’s rapid procurement of ACTs. The Central Fund pur- treatments procured through the Central Fund. chased and delivered more than 2.4 million treatments to these three countries during 2008, saving countless lives.

Building Capacity in National Health Systems • Supporting national Health Management Information Both directly and indirectly, PMI resources help build Systems and malaria surveillance programs to improve health systems and strengthen overall capacity in host the quality and timeliness of data collection, analysis, government’s MOHs and NMCPs. By reducing the and reporting, as well as to strengthen epidemic detec- burden of malaria in highly endemic countries, where tion and response; and MOH statistics indicate that the disease often accounts for 30–40 percent of outpatient visits and hospital • Collaborating with NMCPs and other partners, such admissions, PMI allows critical resources and over- as the U.S. President’s Emergency Plan for AIDS stretched health workers to concentrate on controlling Relief (PEPFAR) and WHO, to strengthen laboratory other childhood illnesses, such as diarrhea and pneumonia. diagnosis of malaria. These efforts to upgrade laboratory In 2008, PMI efforts to strengthen health systems included: services help improve the overall quality of primary health care, diagnosis, and treatment. • Funding for training: more than 35,000 health workers on case management with ACTs, more than 1,600 Looking Ahead health workers in malaria laboratory diagnostics, and In spite of this progress, we cannot afford to be complacent. more than 14,000 health workers in IPTp; Inefficient national supply chain management systems, the intensification of antimalarial drug and insecticide • Providing $8.4 million in FY 2008 funding to help resistance, and weak health information systems all MOHs, NMCPs, and national essential drugs programs hamper malaria and other disease control efforts. to improve the forecasting; procurement; quality Together with our partners, PMI is tackling these chal- control; storage; and distribution of antimalarial and lenges. With the increased funding for malaria in the other drugs, and to train and supervise pharmacy, Tom Lantos and Henry J. Hyde United States Global medical store staff, and health workers to ensure the Leadership Against HIV/AIDS, Tuberculosis, and correct usage of these drugs; Malaria Reauthorization Act of 2008, the USG has the opportunity to expand malaria prevention and treatment efforts across the continent.

7 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov BOX 2 PMI Focus Countries

Round 1

Round 2

Round 3 R

As malaria prevention and treatment activities expand in • Improving malaria surveillance and response as the all 15 focus countries, and malaria declines, some adjust- prevalence of malaria falls, immunity to malaria ments in approach will be necessary. These include: wanes, and the risk of outbreaks increases; and

• Emphasizing laboratory diagnosis of malaria over • Tailoring approaches to prevention and treatment of traditional clinical diagnosis based on the patient’s malaria to the changing malaria situation. symptoms in order to differentiate malaria from other multiple causes of fever;

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 8 CHAPTER 1

“Malaria is not only a disease of poverty; it’s a cause of poverty.” – Robert B. Zoellick, President of the World Bank Group, commenting during the United Nations 2008 Millennium Development Goals Malaria Summit, September 26, 2008

KIM WYLIE/USAID A sprayer practices his technique on a wall in Zanzibar, where indoor residual spraying, in combination with other malaria control efforts, has contributed to a dramatic reduction in the number of confirmed cases of malaria in young children. PMI works with focus countries to train local residents on the proper handling and safe use of insecticides during spraying campaigns.

9 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov THE CHALLENGE OF MALARIA CONTROL

women, and people with HIV/AIDS are the most vul- MALARIA AT A GLANCE nerable groups. Malaria is a leading cause of death in • Each year, an estimated 300 million to 500 African children, accounting for approximately 18 percent million people become ill with malaria, and of deaths in children under five. nearly 1 million die. • Every 30 seconds, an African child dies Although malaria eradication efforts during the 1950s of malaria. and 1960s successfully eliminated or controlled the dis- • More than 80 percent of the world’s malaria ease in some areas outside Africa, malaria remains a deaths occur in sub-Saharan Africa. major killer in Africa due to a combination of biological, • Malaria is a leading cause of death of y oung economic, and political factors. The sub-Saharan climate children in Africa. provides ideal conditions for malaria transmission, while • Malaria is a preventable and treatable disease. • Malaria causes an annual loss of $12 billion, or poverty and political instability create obstacles to suc- 1.3 percent of Africa’s gross domestic product. cessful malaria control efforts. • Malaria accounts for approximately 40 percent of public health expenditures in Africa. Malaria Control Interventions Malaria is both preventable and treatable. Several proven and cost-effective prevention and treatment measures Malaria Transmission and Infection exist. These include insecticide-treated nets (ITNs), indoor Malaria is a blood-borne infection caused by parasites residual spraying (IRS) with insecticides, intermittent and transmitted among human beings by the bite of preventive treatment for pregnant women (IPTp), and female Anopheles mosquitoes. Malaria usually begins as prompt use of artemisinin-based combination therapies a flu-like illness with fever and chills. Mild to moderate (ACTs) for those who have malaria. The appropriate anemia is also common because the malaria parasite mix of prevention and treatment interventions varies infects and destroys red blood cells. Untreated, malaria according to: can result in severe anemia, lung and kidney failure, coma, and death. • The pattern and intensity of malaria disease transmission;

Malaria typically occurs in tropical and subtropical • Mosquito resistance to insecticides and parasite resist- regions of the world, particularly in sub-Saharan Africa, ance to antimalarial drugs; where the mosquito and the malaria parasite thrive. Four species of malaria parasites infect humans, although two species, Plasmodium falciparum and P. vivax, account for about 90 percent of all human infections. In sub-Saharan Africa, the majority of infections are caused by P. falciparum, which causes the most severe form of the disease and almost all deaths worldwide.

Social and Economic Impact Approximately 3.2 billion people worldwide live in areas where they are at risk of malaria transmission. An esti-

mated 300 million to 500 million people become ill THANY/CDC with malaria each year, and nearly 1 million die. More than 80 percent of deaths occur in sub-Saharan Africa. JAMES GA Box 1 shows the distribution of malaria in Africa. While The Anopheles funestus (above) and A. gambiae mosquitoes are the two most important malaria vectors in Africa, where more than all people living in areas where malaria is transmitted can 80 percent of the world's malarial disease and deaths occur. be infected, children under five years of age, pregnant

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 10 lasting ITNs have the insecticide bound to the netting material during production, which enables them to maintain their full protective effect through at least 20 washes, which is equivalent to approximately three years of regular use.

PMI has focused on scaling up ITN coverage in all 15 focus countries. Although ITN activities are tailored to the local conditions and capacities of each country, PMI follows certain principles and best practices in all focus countries:

• Targeting the most vulnerable populations – children under five and pregnant women – while working to expand to universal coverage for all residents when that is in agreement with national strategy, and adequate resources exist;

• Removing cost as a barrier to ITN ownership through provision of free ITNs to the poorest and most vulnerable groups, while allowing market segmentation A MALARIA-FREE FUTURE to increase access to low-cost or highly subsidized nets for those who can afford them; OICES FOR

• Building upon existing mechanisms for delivery, including immunization or health campaigns, antenatal

BONNIE GILLESPIE/V and child health clinics, and the commercial sector; At a hospital in Tanzania, a mother tends to her young child, who is being treated for malaria. PMI focuses on the most vulnerable populations: children under five and pregnant women. • Preferentially procuring and distributing long-lasting ITNs rather than conventional ITNs; and

• The age and pregnancy status of infected persons; and • Educating at-risk populations about the benefits of ITNs and their appropriate use. • Operational feasibility and sustainability. Indoor Residual Spraying Insecticide-Treated Nets IRS, a proven and highly effective malaria control In Africa, malaria-carrying mosquitoes typically bite late measure, involves the coordinated, timely spraying of the at night or in the early morning hours. A net hung over interior walls of homes with insecticides. Mosquitoes are the sleeping area prevents mosquitoes from biting. When killed when they rest on those walls. Sprayed houses are that net is treated with insecticide, it provides greater protected for about four to ten months, depending on protection by repelling mosquitoes and killing those the insecticide used and the housing construction. that land on it. The insecticides used to treat the nets have been approved for safety and efficacy by the World WHO has approved 12 insecticides it considers effective Health Organization (WHO). ITNs have been shown to and safe for use in IRS, including DDT. The choice of reduce all-cause mortality in children under five by insecticide depends on its registration status in-country, about 20 percent and malarial illnesses among children the housing construction (e.g., mud, brick, or wood), under five and pregnant women by up to 50 percent. the duration of the malaria transmission season, and susceptibility of local Anopheles mosquitoes to the ITNs come in a variety of shapes, colors, and sizes, and insecticide. For IRS to be effective, at least 80 percent range in price from $4 to $7. Until a few years ago, of homes in the targeted area must be sprayed. ITNs required re-treatment with insecticide about every six months to maintain their effectiveness. Newer, long-

11 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Prior to PMI, only a few countries in Africa were con- clinics, and (3) creating demand for antenatal care ducting large-scale IRS campaigns, most of them in through health promotion and education activities. southern Africa and the Horn of Africa. PMI has now supported National Malaria Control Programs (NMCPs) Diagnosis and Treatment to launch IRS activities in all 15 focus countries. While Artemisinin drugs are the most rapidly acting and IRS activities are tailored to the local conditions and effective antimalarial drugs currently available. Combined capacities of each country, the following principles and with a second effective antimalarial, so-called artemisinin- best practices are applied in all countries: based combination therapy has become the standard of treatment of malaria in almost all malaria-affected • Completing environmental assessments and develop- regions. The rationale for using combination therapy ing plans for the appropriate handling and safe use of for malaria is that it greatly reduces the probability of the insecticides prior to spraying; emergence of malaria parasites that are drug resistant, and thus prolongs the effective lifetimes of both drugs. • Recruiting and training local residents and government ACTs currently cost 10 to 20 times more than previous health staff to carry out and supervise IRS, building first-line malaria treatments, such as chloroquine, and in-country capacity for future spraying activities; and have a shelf life of just 18 to 24 months. Therefore, good pharmaceutical management is critical to their • Making house-to-house visits prior to spray campaigns effective use. to educate residents about IRS and foster cooperation with spray teams. The high cost of ACTs increases the need for accurate diagnosis of malaria. Currently, most malaria cases are Malaria in Pregnancy diagnosed solely on clinical grounds, without laboratory Malaria infection during pregnancy poses serious health confirmation. Because the symptoms and signs of malaria risks for both the mother and her unborn child. The are nonspecific, many people treated for malaria do not prevention and treatment of malaria during pregnancy have the infection. The result is that costly drugs are depend on a combination of malaria control measures, wasted, and other treatable conditions are missed. including the use of ITNs, prompt and effective treat- Microscopic examination of blood smears is considered ment for malaria, and intermittent preventive treatment. the gold standard for diagnosis, but it requires considerable supervisory and logistics support to sustain high-quality IPTp is a highly effective means of reducing the conse- performance. In recent years, the development and quences of malaria in both the pregnant woman and her unborn child. Pregnant women in their second and third trimesters are administered at least two doses of the drug sulfadoxine-pyrimethamine (SP) at least one month apart. Because antenatal clinic attendance is greater than 70 percent in most African countries, IPTp usually is administered during routine antenatal clinic visits. Costing only $0.10 to $0.12 per treatment dose, IPTp reduces the frequency of maternal anemia, malaria infection of the placenta, and low-birthweight babies and could prevent 75,000 to 200,000 infant deaths each year in Africa.

In all countries where IPTp is recommended, PMI supports strengthening and expanding preventive activities for malaria in pregnancy as part of a partnership between malaria and reproductive health programs. This partner- RICHARD NYBERG/USAID SENEGAL ship includes (1) training health care workers about Community members wear protective gear in preparation for a malaria in pregnancy and the use of IPTp and ITNs in round of spraying in Keur Moussa, Senegal. Residents are educated about IRS and encouraged to participate during house-to-house the context of high-quality antenatal services, (2) pro- visits prior to spray campaigns. curement and distribution of SP and ITNs to antenatal

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 12 BOX 1 Distribution of Malaria in Africa

refinement of rapid diagnostic tests (RDTs) for malaria PMI is supporting procurement and distribution of offer a potentially simpler solution to laboratory diagnosis ACTs, the training and supervision of health workers in of malaria, but these tests have their limitations. There appropriate malaria treatment, and the improvement of have been problems with poor quality control during laboratory diagnosis of malaria, including utilization of manufacture, and all available RDTs become unstable at test results. PMI also works with NMCPs to ensure that high temperatures and humidity. In addition, health care appropriate policies are in place and antimalarial drugs workers may not accept negative test results when those are procured for the management of severe malaria. In results do not agree with their clinical impression of the addition, because many people in Africa cannot access cause of a patient’s illness. facility-based treatment services in a timely manner, PMI is working with host governments to expand communi-

13 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov ty-based malaria treatment and improve the diagnosis and treatment of malaria in the private sector.

President’s Malaria Initiative: A Partner in Malaria Control Former President George W. Bush described the defeat of malaria as an “urgent calling,” and, in 2005, created the President’s Malaria Initiative, a five-year, $1.2 billion initiative to reduce malaria mortality by 50 percent in 15 African countries with a high burden of malaria. International development experts agree that controlling malaria in Africa is critical to the continued development of this region, as malaria casts a shadow over not only USAID GHANA health, but also educational attainment, worker produc- PMI uses community mobilization activities, such as this one in tivity, and economic development. This call has been Ghana, to reach mothers of children between 18 months and five taken up by the U.S. Congress, most recently with the years. Children in this vulnerable age group no longer visit clinics for routine vaccinations and often miss out on free distribution passage in July 2008 of the Tom Lantos and Henry J. of ITNs. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008. This Act authorizes an increase in funding to a total of $5 billion over five years for the fight against malaria.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 14 CHAPTER 2

“With the assistance of the President’s Malaria Initiative, we are on the verge of conquering malaria [in Zanzibar]…. Think what it would mean to the people of my country to eliminate all these deaths and sufferings, and what it would mean to our economy, based on tourism and agriculture, to not have this strain on our productivity and reputation.” – Mohamed Saleh Jiddawi, M.D., Zanzibar Principal Secretary, Ministry of Health and Social Welfare, White House Summit on Malaria, Washington, D.C., December 14, 2006

JULIE WALLACE/USAID Residents of Gumbiro Village, Tanzania, participate in a villagewide malaria education and mobilization event. Angola, Tanzania, and Uganda were selected in June 2005 to be the first three countries to participate in PMI.

15 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov PROGRESS TO DATE IN PMI ROUND 1 COUNTRIES: ANGOLA, TANZANIA, AND UGANDA

Angola, Tanzania, and Uganda were the first three positive for malaria in children under two years of age countries selected for PMI activities, and work supported attending health clinics, from 22 to less than 1 percent. by PMI began in these countries in 2006. Now, after This chapter provides details of the progress in these nearly three years of scaling up malaria prevention and three countries. treatment measures, impact is being seen on malaria- related illnesses and childhood mortality in several areas. For example, following indoor residual spraying (IRS) ANGOLA campaigns in Muleba District, Tanzania, and Kihihi Malaria in Angola District, Uganda, significant reductions in laboratory- Malaria remains a major health problem in Angola, confirmed cases of malaria were reported. On the island estimated by the Ministry of Health (MOH) to account of Zanzibar, increased coverage with insecticide-treated for about 60 percent of hospital admissions and 35 percent nets (ITNs) together with IRS campaigns, were associated of the overall mortality in children under five years of with a dramatic fall in the proportion of blood smears age. As a result of severe damage to the country’s health

PMI RESULTS IN ANGOLA1 Year 1 Year 2 Year 3 Cumulative Intervention Indicator (2006) (2007) (2008) Results ITNs procured 540,949 294,200 734,198 1,569,347 (distributed) (540,949) (0) (339,440) (880,389) Insecticide- Treated Nets ITNs procured by other partners and distributed 0 0 109,624 109,624 with PMI support Late 2007/Early 2008: 2,104 Spray personnel trained 350 582 – Late 2008: 565 Indoor Houses targeted 119,303 130,218 Late 2007/Early 2008: 154,662 (90%) Residual – (90%) (85%) Late 2008: 140,000 (97%) Spraying (% sprayed) Late 2007/Early 2008: 745,061 People protected 590,398 612,776 – Late 2008: 678,030 Malaria in Health workers trained 1,450 290 1,481 – Pregnancy in IPTp Health workers 1,283 290 1,357 – trained in ACT use Health workers trained 0 3742 1,3563 – Diagnosis in malaria diagnostics and Treatment ACT treatments 587,520 2,033,200 3,035,520 5,656,2404 procured (distributed) (0) (1,101,801) (2,985,958) (4,087,759) RDTs procured 129,875 375,000 375,000 879,8755 (distributed) (0) (101,000) (380,875) (481,875) BUDGET $1.7 million (FY05 jump start funds), $7.5 million (FY06), $18.5 million (FY07), $18.8 million (FY08) 1 PMI measured Year 1, 2, and 3 results in terms of process indicators. Interim results for PMI in Angola will be obtained from the 2008 nationwide Multiple Indicator Cluster Survey, conducted in early 2009. Results reported in this table are up-to-date as of January 1, 2009. 2 These health workers were trained in IPTp, case management/ACTs, and malaria diagnosis. Of these, 84 health workers were trained in malaria laboratory diagnosis only. 3 These health workers were trained in IPTp, case management/ACTs, and malaria diagnosis. Of these, 136 health workers were trained in malaria laboratory diagnosis only. 4 A total of 404,134 artemether-lumefantrine treatments procured in 2007 and 2008 were stolen from the central warehouse and two local airports in Angola. 5 Approximately 23,000 RDTs were damaged by rain during port clearance and had to be discarded.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 16 FIGURE 2.1 • Distributed 109,624 long-lasting ITNs (procured by Allocation of $18.8 Million other partners) through the private sector in urban PMI Budget in Angola, FY08 areas; and (Proportion of budget spent on commodities: 52%) • Created demand for and promoted correct hanging and use of ITNs through house-to-house visits, radio spots, and drama shows.

PMI is also supporting national and international nongovernmental organizations (NGOs) in several provinces to assist with the distribution and promotion of ITNs in hard-to-reach areas. An example of this is the Episcopal Relief and Development (ERD) project in Mucaba District of Uige Province (population 92,000), one of the Malaria Communities Program recipients in Angola. ERD has focused its efforts on establishing community- based malaria prevention programs. As a result, ITN distribution in the area has increased significantly in the past year. According to a recent survey carried out by Note: The Malaria Communities Program awarded a five-year ERD, the proportion of households in Mucaba District grant of $1,482,022 to Episcopal Relief and De velopment with one or more ITNs increased from 8 percent to 86 in FY07. percent in less than one year. Currently, 80 percent of pregnant women and 72 percent of children under five are reported to be sleeping under an ITN in this area, infrastructure due to the prolonged civil war, only an coverage figures that are close to reaching the 85 percent estimated 30 percent of the population has access to PMI target. government health facilities. Indoor Residual Spraying Insecticide-Treated Nets Before PMI began work in Angola in 2005, no large-scale The National Malaria Control Program (NMCP) has a IRS had been conducted by the NMCP for many years. multipronged approach to ITN distribution, including Spraying supported by PMI began in 2006 in three free distribution through large-scale health campaigns, southern provinces with epidemic-prone malaria. Over free distribution through antenatal and child health the past year, based on discussions with the NMCP, clinics, and commercial sales of full-cost or subsidized spraying was continued in only one of these three nets. According to UNICEF, more than 3 million ITNs southern provinces, Huila Province, which has the have been distributed since the July 2006 large-scale highest malaria burden, and was initiated in one new integrated measles-ITN campaign. Thus, it is expected province, Huambo, where year-round, more intense that the nationwide Multiple Indicator Cluster Survey, malaria transmission occurs. During Year 3, PMI: conducted in early 2009, will show a dramatic increase in ITN ownership and use when compared with results • Supported spraying of 139,700 houses in the three from the 2006 Malaria Indicator Survey. During Year 3 southern provinces of Cunene, Huila, and Namibe in of implementation, PMI: late 2007 and early 2008. Ninety percent of the 154,662 houses targeted for spraying were successfully • Procured 734,198 long-lasting ITNs, most of which sprayed, and 745,061 residents were protected. More arrived in country in 2008 for free distribution than 2,000 local personnel were trained to conduct through antenatal and child health clinics; and oversee operations;

• Distributed 339,440 long-lasting ITNs (procured by • Funded spraying of 135,606 houses in Huila and PMI) free of charge through antenatal and child Huambo Provinces with a synthetic pyrethroid insecti- health clinics and outreach programs; cide, lambda-cyhalothrin, in late 2008. Ninety-seven percent of all houses targeted for spraying were sprayed,

17 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov It Begins With an ITN: Protecting Angola’s Women and Children Against Malaria

Beatriz and her baby, Surpresa, residents of the municipality of Cazenga in Luanda Province, are thriving and in good health. In fact, all of Beatriz’ children are alive and well. Ever since the birth of her first child, Beatriz and her four daughters have slept under ITNs. Beatriz sleeps with Surpresa while her other daughters sleep under the same net in a different bed. None of the girls has had malaria because Beatriz knows the importance of making sure that her children sleep under their nets every night. Many children in Angola are not as fortunate. The death toll caused by malaria in Angola is alarming, but the good news is that the majority of these deaths can be a verted. Providing free long-lasting ITNs to women and children is a simple and effective way of protecting them against the mosquito bites that lead to malaria. Thanks to the support of PMI and other par tners, long-lasting ITNs are now being UNICEF procured, distributed, and used all over Angola as part of Beatriz and her daughter, Surpresa, sleep under an ITN every night. PMI funds the distribution of free ITNs in Angola as an effort to integrate primary health services to reduce well as efforts to promote the correct use of the nets. mortality and morbidity among women and children.

and a total of 678,030 residents were protected by the Diagnosis and Treatment campaign. A total of 565 provincial and municipal Artemether-lumefantrine (AL), an ACT, procured and health staff, as well as community members, were distributed with PMI funds, has contributed to the trained to conduct and oversee spraying activities; and expansion of ACT use in 1,075 health facilities in 156 of Angola’s 164 districts. According to MOH reports, • Promoted acceptance of the IRS program and compli- more than 160,000 AL treatments are being administered ance with spray teams through house-to-house visits monthly. PMI also funded the strengthening of the and distribution of informational materials. MOH pharmaceutical logistics system and is seconding a technician to the National Essential Drugs Program to Malaria in Pregnancy assist with pharmaceutical management issues. The Intermittent preventive treatment for pregnant women NGOs that PMI is supporting at the provincial level are (IPTp) has now been implemented in all of Angola’s 18 working with the NMCP to oversee the rollout of ACTs provinces and all 164 districts. This represents a dramatic in five different provinces. Based on the success of this scale-up since 2005, when PMI began work in the country trial and, at the request of the NMCP, PMI will support and IPTp had been implemented in fewer than 10 dis- expansion of ACT implementation, together with tricts. Training of health workers and provision of drugs improved malaria in pregnancy services and distribution for IPTp have been carried out, together with that for of ITNs, into three new provinces through additional artemisinin-based combination therapies (ACTs). During NGO partners in 2009. 2008, with PMI support, 1,481 health workers were trained in IPTp, case management, and correct use of To broaden access to ACTs, particularly in areas that are ITNs. All sulfadoxine-pyrimethamine (SP) drug needs underserved by the MOH, PMI is working with the for IPTp are being met by the MOH and the Global British NGO MENTOR to conduct a trial of AL distri- Fund. For the period of January–December 2008, sup- bution for the treatment of uncomplicated malaria port from PMI and other partners in Angola resulted in through private sector outlets in Huambo Province. If more than 300,500 pregnant women receiving their first successful, the NMCP may choose to expand this effort dose of sulfadoxine-pyrimethamine and more than to additional provinces in the future. 228,400 receiving their second dose.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 18 During Year 3, PMI: Huambo Province showed that health facility staff were generally well prepared to handle malaria patients. All • Made an emergency procurement of 3,035,520 AL facilities had staff trained in the new ACT policy and in treatments to avert a nationwide stockout of ACTs. malaria diagnostic testing, although supervision was A total of 2,985,958 of these treatments have already infrequent and health workers did not trust negative been distributed; diagnostic test results. The first-line ACT, AL, was in stock at the time of the visit in all facilities, although • Supported training of 1,357 health workers in case more than half of the facilities had stockouts that management with ACTs; occurred in the months before the survey. Since the survey, refresher training for health workers and more • Supported training of 1,356 health workers in the frequent supervisory visits have been carried out. laboratory diagnosis of malaria with microscopy and/or rapid diagnostic tests (RDTs); and TANZANIA • Procured 375,000 RDTs and distributed a total of Malaria in Tanzania 380,875 (some procured in Year 2) to improve diag- Tanzania is made up of the mainland, with a population nostic accuracy within health centers. of about 38 million, and the islands of Zanzibar, with a population of about 1 million. Nearly all of the population Pilferage of ACTs at the central warehouse and local air- live in areas where malaria is transmitted during at least ports was a major problem in 2008. A total of 404,134 one month of the year. On Zanzibar, malaria has been treatments were stolen. This was reported to the USAID brought under control during the last two to three years, Inspector General and the Government of Angola; but improved surveillance and epidemic response capa- authorities are conducting an investigation. To avoid a bilities will be required to prevent a resurgence of disease. repetition of this problem, stringent controls have now been established to ensure rapid and secure passage of Insecticide-Treated Nets PMI malaria drugs through customs, and to secure Although the 2007–2008 Tanzania HIV/AIDS and short-term storage in the capital and transportation to Malaria Indicator Survey (THMIS) shows that ITN the provinces. In addition, PMI is working with the ownership rose, from 23 to 39 percent in five years as a NMCP to strengthen the existing tracking system to result of commercial sales supported by social marketing verify that PMI commodities reach and are correctly and subsidies for ITNs for pregnant women and infants used by recipients. through the Tanzania National Voucher Scheme, only 26 percent of pregnant women and 25 percent of children Monitoring and Evaluation under five slept under their ITNs the night before the A nationwide Multiple Indicator Cluster Survey, com- survey. Between 2004 and 2007, the prevalence of severe bined with a World Bank Household Expenditure and anemia, to which malaria is a major contributor, fell Income Survey, began in May 2008. Data collection in from 11 to 8 percent. the 12,000 households included in the survey is expected to last one year and will provide interim coverage results As a result of the slower-than-expected progress in for PMI related to ITNs, ACT, and IPTp. During 2008, achieving high ITN ownership and usage in Tanzania, PMI contributed funding to this survey. Preliminary the MOH made several important changes in its ITN results should be available in April 2009 and are expected policy during the past year. The voucher top-up value to show significant improvements in coverage of ITNs, that the buyer has to pay will be reduced to Ts 500 ACTs, and IPTp. ($0.45) to enable families to afford a long-lasting ITN rather than a regular ITN. In addition, a catch-up cam- Two other surveys were conducted by PMI in Angola paign to distribute free long-lasting ITNs nationwide to during 2008. A blood smear and entomologic survey in children under five will be conducted in 2009. The the capital, Luanda, confirmed that very little malaria NMCP has also decided to move toward a universal transmission occurs there except in peripheral areas of coverage strategy that will be implemented in late 2009 the city. This finding allows the NMCP and its partners with Global Fund Round 8 support. to target their malaria control efforts to higher-risk areas in other parts of the country. A health facility survey in

19 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov PMI RESULTS IN TANZANIA1 Year 1 Year 2 Year 3 Intervention Indicator Cumulative Results (2006) (2007) (2008) Mainland: 113,560 Mainland: 113,560 ITNs procured Zanzibar: (113,560) (113,560) 130,000 0 (distributed) (130,000) Zanzibar: 30,000 Zanzibar: 160,000 (0) (130,000) ITNs procured by other partners and 0 0 Mainland: 350,0002 Mainland: 350,000 distributed with PMI support Insecticide- Mainland: 1,844,225 Mainland: 3,720,225 Treated Nets ITN vouchers Mainland: Mainland: 1,493,100 (1,008,647) (1,370,841) distributed 382,900 (362,194) (redeemed)3 Zanzibar: 53,549 Zanzibar: 53,549 (26,064) (26,064) Insecticide treat- Mainland: 875,000 Mainland: 3,400,000 Mainland: 4,275,000 ment kits procured 0 (875,000) (3,400,000)4 (4,275,000) (distributed) ITNs re-treated 0 0 Mainland: 32,453 Mainland: 32,453 with insecticides Mainland: 164 Spray personnel Zanzibar I: Mainland: 167 Zanzibar II: 570 – trained 536 Zanzibar IV: 521 Zanzibar III: 570 Mainland: 40,197 Mainland: 100,258 (89%) (96%) Houses targeted Zanzibar I: 212,244 Indoor (% sprayed) Zanzibar II: 217,737 Zanzibar IV: 218,816 (96%) – Residual (90%) (97%) Spraying Zanzibar III: 218,816 Zanzibar (Outbreak): (97%) 3,588 (100%) Mainland: 448,690 Mainland: 159,579 Zanzibar I: Zanzibar IV: 1,120,381 People protected Zanzibar II: 1,062,865 – 1,018,156 Zanzibar (Outbreak): Zanzibar III: 1,120,381 17,940 Malaria in Health workers Mainland: Mainland: 4,145 Mainland: 1,158 – Pregnancy trained in IPTp 376 Zanzibar: 24 Health workers Mainland: Mainland: 1,011 Mainland: 1,767 – trained in ACT use 4,217 ACT treatments Mainland: Mainland: 694,050 Mainland: 146,730 Mainland: 1,220,940 procured 380,160 (494,050) (346,730) (1,220,940) (distributed) (380,160) Diagnosis and Treatment Mainland: 775,000 Mainland: 400,200 Mainland: 1,075,000 Mainland: 2,250,200 RDTs procured (150,000) (1,025,200) (275,000) (1,450,200) (distributed) Zanzibar: Zanzibar: 150,000 Zanzibar: 0 Zanzibar: 250,000 100,000 (0) (150,000) (250,000) (100,000) BUDGET $2 million (FY05 jump start funds), $11.5 million (FY06), $31 million (FY07), $33.7 million (FY08) 1 PMI measured Year 1, 2, and 3 results in terms of process indicators. Interim results for PMI in Tanzania will be obtained from a 2008 nationwide household survey. Results reported in this table are up-to-date as of January 1, 2009. In addition to results reported here, PMI supported larviciding activities that benefited more than 300,000 people during Years 1 and 2, and 614,000 people during Year 3. 2 These ITNs were procured by Malaria No More. 3 There is a lag time of several months between the distribution of vouchers and their redemption for a mosquito net. 4 These insecticide treatment kits were bundled with new nets for free distribution via the voucher program or sold as stand-alone kits through the commercial sector. During Year 3, PMI also distributed 1,993,599 insecticide treatment kits procured by other donors.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 20 FIGURE 2.2 women vouchers) on the mainland and 26,064 Allocation of $33.7 Million vouchers on Zanzibar in 2008; and PMI Budget in Tanzania, FY08 (Proportion of budget spent on commodities: 52%) • Procured and distributed 3,400,000 insecticide treatment kits and distributed an additional 1,993,599 kits funded by other donors. This support helps to ensure that nets distributed in Tanzania are treated with insecticide.

Indoor Residual Spraying PMI has supported four rounds of IRS on the Zanzibar islands and two on the mainland since 2006. This intervention continues to be highly successful, with an average of at least 89 percent of targeted houses being sprayed per round. During 2008, PMI supported a fourth round of spraying on Zanzibar, in addition to focal spraying in Bumbwini District, in response to a malaria outbreak. On the mainland, PMI supported a second round of IRS in Muleba District, where the frequency of malaria infections has continued to decline (Box 1), and Note: In FY07, the Malaria Communities Program awarded a first round in Karagwe District, in northwestern a three-year grant of $899,908 to Lutheran World Relief Tanzania. During Year 3, PMI: and a five-year grant of $1,499,998 to the Christian Social Services Commission. • Supported the spraying of 212,021 houses (97 percent of target) and protected 1,120,381 people on Zanzibar, in addition to focal spraying of 3,588 houses (100 PMI has supported several elements of Tanzania’s ITN percent of target) in Bumbwini District that protected strategy, including the nationwide expansion of the ITN 17,940 residents; voucher programs for infants and pregnant women, training of health facility workers on the voucher • Supported the spraying of 36,860 houses (92 percent scheme, procurement of insecticide treatment kits for of target) and protected 181,343 people in Muleba bundling with nets, and procurement of long-lasting District, on the mainland; ITNs for the campaign. During Year 3, PMI: • Supported the spraying of 59,177 houses (98 percent • Procured and distributed 113,560 long-lasting ITNs of target) and protected 267,347 people in Karagwe for a pilot campaign in Mpanda District, on the District, on the mainland; and mainland, in October 2008. Preliminary results from a postcampaign evaluation indicate that it contributed • Trained 688 local residents to implement spray operations. to an increase in household ownership of one or more ITNs to 85 percent. PMI also committed to procuring Larviciding 1 million long-lasting ITNs for the national catch-up PMI has been supporting a larviciding program in 15 campaign for children under five that will be conducted wards of urban Dar es Salaam that covers a population in 2009; of 614,000. Field teams map mosquito breeding habitats, conduct regular inspections, and treat active breeding • Procured 30,000 long-lasting ITNs that will be dis- sites with a biological larvicide, Bacillus thuringiensis var tributed by the Zanzibar Malaria Control Program as israelensis H-14. Systematic monitoring in these areas a part of its universal coverage strategy in 2009; showed a dramatic reduction in human-biting rates by Anopheles gambiae, the major malaria vector, following • Provided support for the voucher program that result- the larviciding program. More importantly, a household ed in 1,008,647 vouchers being redeemed for an ITN survey demonstrated up to 69 percent reduction in (463,137 infant vouchers and 545,510 pregnant

21 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov malaria prevalence among children under five years of age, from 20 percent in 2006 to 6 percent in 2007.

Malaria in Pregnancy PMI has supported the scale-up of IPTp through the focused antenatal care (FANC) approach recommended by the World Health Organization (WHO). Between 2005 and 2008, the proportion of pregnant women who received two or more doses of IPTp rose, from 22 to 30 percent. In Year 3, PMI:

• Provided funding for the training of 4,169 health

workers and supervisors in FANC; USAID Fatuma Mamudi (right) gets tested for malaria with a RDT at • Trained FANC trainers for all 131 districts on the the Ikwiriri Health Center in Tanzania. WHO recommends that mainland; and treatment of all older children and adults with suspected malaria be based on laboratory diagnostic testing. In 2008, PMI purchased more than 1 million RDTs for use in Tanzania. • Addressed national stockouts in sulfadoxine- pyrimethamine for IPTp by supporting quantification of SP needs and tracking of drug stocks by the MOH. revealed that, on average, ACTs for all four weight pre- sentations were available in 80 percent of public Diagnosis and Treatment facilities. In Year 3, PMI: PMI has supported a comprehensive approach to case management, including support for the rollout of RDTs, • Trained 1,500 health facility staff and 267 private health worker training on case management and supply sector staff from Accredited Drug Dispensing Outlets chain management for ACTs, and procurement of ACTs (ADDOs), who are private drug sellers who have been to fill critical gaps in the public and private sectors. A trained and authorized to dispense ACTs at a highly rapid survey of 116 facilities conducted early in 2008 subsidized price;

BOX 1 Decline in Malaria Prevalence Following Indoor Residual Spraying in Muleba District, Tanzania

During 2008, PMI continued its support of indoor residual spraying in Muleba District, in northwestern Tanzania, consolidating the gains in malaria control seen during the previous year. A further drop of 55 percent in malaria- positive blood smears in patients of all ages was obser ved during 2008. In total, between 2006 and 2008, the prevalence of malaria during the peak transmission period of J une–July fell by 73 percent.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 22 • Distributed 200,000 ACT treatments (procured in FIGURE 2.3 Year 2) through private sector ADDOs; Allocation of $21.8 Million PMI Budget in Uganda, FY08 • Procured and distributed 146,730 ACT treatments to (Proportion of budget spent on commodities: 40%) the United Nations High Commissioner for Refugees for use in refugee camps;

• Procured 1,075,000 RDTs, and distributed 275,000 on the mainland and 150,000 on Zanzibar; and

• Supported the integration of ACTs into the new MOH integrated commodity logistics system, a pull system that will be rolled out across all 21 regions by the end of 2009.

Monitoring and Evaluation PMI continues to work closely with the NMCP, the Zanzibar Malaria Control Program, and other implementation partners to strengthen the national monitoring and evaluation framework for malaria control in Tanzania. PMI supported the recently completed Note: The Malaria Communities Program awarded a three-year THMIS, the first combined HIV/AIDS and Malaria grant of $1,499,999 to Minnesota International Health Indicator Survey in Tanzania. The 2007–2008 Malaria Volunteers in FY07. Indicator Survey results will serve as an interim measure of NMCP and PMI progress. Surveillance of malaria morbidity and mortality at four sentinel sites on the • Assisted in establishing sentinel site surveillance to mainland was launched in 2008. In addition, a malaria monitor malaria morbidity and mortality at six sites early case detection and reporting system was established on Zanzibar; and on Zanzibar in mid-2008 to provide weekly data for a rapid response in the event of an outbreak. During Year • Assisted in developing a written monitoring and 3, PMI: evaluation plan for both the NMCP and the Zanzibar Malaria Control Program.

UGANDA Malaria in Uganda OGRAM Malaria is the leading threat to the health of Uganda’s OL PR population and, according to the MOH, is responsible for approximately 40 percent of outpatient visits, 25 percent of inpatient visits, and nearly half of all deaths

AR MALARIA CONTR in children under five. Nearly 94 percent of Uganda’s population of 29 million people live in high-transmission

AZY/ZANZIB areas and are exposed to the disease throughout the year. AL-MAF Insecticide-Treated Nets AHIYD The scale-up of long-lasting ITNs and promotion of net

ABDUL-W retention and proper and consistent use among vulnerable Makame Haji Makame of the Zanzibar Malaria Control Program groups are priorities of the NMCP. Based on the 2006 reviews data from the malaria case detection and reporting system. Demographic and Health Survey, only 16 percent of A spike in the number of laboratory-confirmed malaria cases can alert officials to a suspected outbreak of malaria. households owned at least one ITN, and approximately 10 percent of children under five and pregnant women

23 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov PMI RESULTS IN UGANDA1 Year 1 Year 2 Year 3 Intervention Indicator Cumulative Results (2006) (2007) (2008) ITNs procured 376,444 1,132,5322 480,000 1,988,976 (distributed) (305,305) (683,777)2 (999,894) (1,988,976)

ITNs procured by other partners and 0 369,9003 0 369,900 distributed with Insecticide- PMI support Treated Nets ITNs sold with PMI marketing 586,284 932,033 1,115,074 2,633,391 support

ITNs re-treated 505,573 71,086 77,131 653,790 with insecticides Spray personnel 450 4,062 4,945 – trained Indoor Houses targeted 107,634 455,906 622,583 Residual – Spraying (% sprayed) (96%) (98%) (94%)

People protected 488,502 1,865,956 2,211,388 –

Health workers 168 807 649 – Malaria in trained in IPTp Pregnancy SP treatments pro- 18,333 18,333 0 0 cured (distributed) (2,556) (2,556) Health workers 2,844 12,637 9,159 – trained in ACT use

Health workers trained in malaria 0 0 100 – diagnostics

Diagnosis ACT treatments 1,140,480 261,870 1,402,350 and Treatment procured 04 (distribution (227,827) (227,827) (distributed) under way)

ACTs procured by other partners and 0 8,709,1405 112,3305 8,821,470 distributed with PMI support

BUDGET $510,775 (FY05 jump start funds), $9.5 million (FY06), $21.5 million (FY07), $21.8 million (FY08)

1 PMI measured Year 1, 2, and 3 results in terms of process indicators. Interim results for PMI in Uganda will be obtained during 2009 from a nationwide household survey. Results reported in this table are up-to-date as of January 1, 2009. 2 In PMI’s Second Annual Report, the number of ITNs procured and distributed during Year 2 was incorrect. The data reported here have been corrected. 3 These ITNs were procured by Malaria No More. 4 During Year 2, PMI did not procure any ACT treatments because sufficient quantities of ACTs were procured by other partners such as the Global Fund. 5 These treatments were procured by the Global Fund.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 24 scale IRS campaign in Uganda was implemented in Kabale District. It was met with remarkable public acceptance and attained high coverage. The following year, more than 446,000 houses were sprayed in the districts of Kabale and Kanungu, protecting 1.8 million people. During Year 3, PMI continued to expand the IRS program, including: A MALARIA-FREE FUTURE

• Spraying 575,903 houses in five northern districts, OICES FOR including use of DDT in Apac and Oyam districts, protecting more than 2.2 million people, many of whom were internally displaced persons. Ninety-four BONNIE GILLESPIE/V percent of the 622,583 houses targeted for spraying At a rural clinic in Uganda, waiting patients are shown the correct way to hang a mosquito net. were sprayed;

• Training 4,945 local personnel to conduct, supervise, slept under an ITN the night before the survey. In its and monitor IRS operations; and first two years, PMI procured and distributed more than 1.3 million long-lasting ITNs in Uganda to complement • Conducting massive community sensitization, educa- other partner contributions. To further increase owner- tion, and mobilization drives through cinema programs, ship and maximize access and usage, in Year 3, PMI: radio announcements, talk shows, community meetings, and print media to make residents aware of the value • Procured 480,000 long-lasting ITNs and distributed of IRS and the need to cooperate with spray teams. 999,894 nets. Nets were distributed via three channels: Malaria in Pregnancy - Through rolling mass campaigns, 588,563 were Despite a long-standing policy promoting IPTp, only 16 distributed for free, primarily in eastern Uganda, percent of pregnant women receive the recommended an area not reached by previous campaigns; two doses of SP in Uganda. To improve this situation - Through antenatal clinics, 287,342 were distributed and draw upon previous investments, PMI trained an free to pregnant women and children under five in additional 649 health workers in IPTp in two northern northern Uganda; and regions and distributed information, education, and communication materials on malaria in pregnancy during - Through community-based organizations (CBOs), Year 3. In addition, PMI supported efforts to expand and 123,989 were distributed for free to pregnant strengthen access to and utilization of IPTp in the private women and children under five. More than 20 sector. In Year 3, PMI procured 18,333 treatments of SP, CBOs participated in this novel approach that of which 2,556 have been distributed. The Global Fund capitalized on CBOs’ interactions with difficult- continues to meet most of the needs for SP treatment. to-reach populations. Diagnosis and Treatment • Supported the sale of 1,115,074 long-lasting ITNs To increase access to ACTs at the community level, through market stimulation; Uganda endorses the use of ACT for management of fever in children under five. In Years 1 and 2, PMI sup- • Re-treated 77,131 mosquito nets with insecticide; and ported the rollout of home-based management of fever activities in nine conflict-affected districts in northern • Supported comprehensive community education and Uganda. In addition, PMI provided technical assistance behavior change campaigns for net retention and in pharmaceutical management and drug quality control proper use. to the National Drug Authority. During Year 3, PMI:

Indoor Residual Spraying • Procured more than 1.1 million ACT treatments in an The NMCP has also prioritized a phased expansion of emergency response to stockouts; IRS. In 2006, with PMI support, the first-ever large-

25 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov • Distributed 112,330 ACT treatments that were procured by the Global Fund;

• Trained 9,159 health workers in ACT use and 100 laboratory technicians in malaria microscopy;

• Trained 314 health workers in drug and logistics management in northern Uganda;

• Trained 292 health workers in severe malaria management; and

• Assisted regulatory authorities in establishing an antimalarial drug quality monitoring program and provided technical support for quantification and forecasting of drugs to minimize the number of treatment stockouts.

Monitoring and Evaluation The MOH, with PMI support, conducted a national health facility survey to evaluate information on the availability and quality of malaria treatment. The results of this survey were released in September 2008 and A MALARIA-FREE FUTURE demonstrate major improvements in malaria-related health services, but also highlight the need for improvements in OICES FOR service and commodity continuity and diagnostic capacity. For example, first-line treatments were available in approximately 80 percent of health facilities, and ITNs BONNIE GILLESPIE/V were available in 76 percent of health facilities; however, A Ugandan community health worker holds packets of artemether-lumefantrine, an ACT used to treat malaria. The stockouts are frequent and just 5 percent of facilities packaging provides easy-to-understand information on the correct offered ITNs free to antenatal clinic clients. Results will dosage, which is based on weight. These packets are for children; be used to guide further resource distribution. PMI is older children get two pills twice a day. helping to support ten sentinel sites in eight districts to collect monthly data on malarial illnesses. In addition, PMI collaborated with the U.S. President’s Emergency Plan for AIDS Relief in planning an integrated nationwide Malaria/AIDS Indicator Survey, scheduled to begin in May 2009.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 26 CHAPTER 3

“With a coordinated effort and harmonization of actions and activities, there’s no doubt that we can get the results.” – President Paul Kagame of Rwanda, commenting during the United Nations 2008 Millennium Development Goals Malaria Summit, September 26, 2008

DEBBIE GUEYE/USAID SENEGAL Mareme Diouf and her daughter are the beneficiaries of a long-lasting ITN provided through a PMI-supported mass distribution of ITNs in their village of Thiobe, Senegal, during a micronutrient supplementation day. PMI has been working in Senegal, as well as Malawi; Mozambique; and Rwanda, since 2006.

27 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov PROGRESS TO DATE IN PMI ROUND 2 COUNTRIES: MALAWI, MOZAMBIQUE, RWANDA, AND SENEGAL

In all four PMI Round 2 countries – Malawi, Insecticide-Treated Nets Mozambique, Rwanda, and Senegal – considerable Malawi is one of the first countries to have distributed progress has been made in the fight against malaria. More ITNs through antenatal clinics and has been a leader in children and pregnant women are sleeping under insecti- sub-Saharan Africa in making ITNs available and acces- cide-treated nets (ITNs); effective drugs are now available sible to vulnerable populations. The national policy, in health facilities and in communities to treat malaria revised in February 2008, calls for free distribution of patients; and homes are being sprayed with insecticides to ITNs to pregnant women through antenatal clinics and reduce mosquito populations and protect residents from to children under five who attend clinics for immunization malaria. In Rwanda, for example, preliminary results of a services or illness. In addition, children under five living 2008 nationwide household survey showed a nearly four- in rural areas should receive a free net at least once every fold increase in the proportion of children sleeping under three years through an ITN campaign. Since July 2007, ITNs, from 25 to 58 percent when compared with a simi- PMI has been the primary supporter of the clinic-based lar survey in 2005. In addition, a 32 percent reduction in ITN distribution program, with the Global Fund sup- under-five childhood mortality (from 152 to 103 deaths porting ITN campaigns. During Year 2, PMI: per 1,000 live births) was seen over this period. This chapter details malaria control achievements in the four PMI • Procured 849,578 long-lasting ITNs, which the Round 2 countries during the past year. National Malaria Control Program (NMCP) distributed for free through clinics. An April 2008 survey in eight districts showed that ITN ownership in those MALAWI areas had reached 51 percent; and Malaria in Malawi Malaria has always been a major health problem in • PMI supported information, education, and commu- Malawi. It is endemic in 97 percent of the country, nication (IEC) campaigns to promote correct and although there is growing evidence that the rapid scale- regular use of ITNs at both the national and commu- up of malaria prevention and control measures during nity levels through national partners, small grants to the last two to three years is producing a significant community-based and nongovernmental organizations, reduction in the frequency of malaria infections and and through PMI’s Malaria Communities Program. associated anemia.

PMI RESULTS IN MALAWI1 Year 1 Year 2 Cumulative Intervention Indicator (2007) (2008) Results Insecticide-Treated ITNs procured 1,039,400 849,578 1,888,978 Nets (distributed) (211,995) (849,578) (1,061,573) Spray personnel trained 300 309 – Indoor Residual Houses targeted 29,513 26,562 – Spraying (% sprayed) (91%) (93%) People protected 126,126 106,450 – Malaria in Health workers trained 0 2,747 2,747 Pregnancy in IPTp Health workers 0 5,315 5,315 Diagnosis trained in ACT use and Treatment ACT treatments procured 4,694,013 4,501,740 9,195,753 (distributed) (4,694,013) (3,579,278) (8,273,291) BUDGET: $2 million (FY06 jump start funds), $18.5 million (FY07), $17.8 million (FY08) 1 PMI measured Year 1 and Year 2 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 28 FIGURE 3.1 • Trained 2,747 health workers in IPTp, including Allocation of $17.8 Million health facility and community health workers. PMI Budget in Malawi, FY08 Supportive supervisory visits were made to each facility (Proportion of budget spent on commodities: 66%) to follow up on these trainings; and

• Launched an IEC campaign via mass media and community volunteers to encourage pregnant women to attend the recommended number of antenatal clinic visits and to make those visits at the appropriate times. Through the Malaria Communities Program, 1,290 community volunteers were trained in IEC related to IPTp.

Diagnosis and Treatment In late 2007, PMI supported the successful launch of Malawi’s new national malaria treatment policy by providing all of Malawi’s artemether-lumefantrine (AL), an artemisinin-based combination therapy (ACT), needs for Note: The Malaria Communities Program awarded a five-year an 18-month period. It is expected that future ACT grant of $1.5 million to the Christian Ref ormed World Relief needs at the health facility level will be largely met by the Committee in FY07. successful Global Fund Round 7 grant, which was signed in late 2008. An ACT gap remains at the community Indoor Residual Spraying (IRS) level, where effective antimalarials are not readily avail- PMI supported an initial round of IRS from November able or affordable. During Year 2, PMI: 2007 through March 2008 in rural areas around the Dwangwa Sugar Estates, in Nkhotakota District. In late 2008, a second round of IRS was conducted in the same area. During this second round of spraying, PMI supported:

• Spraying of 24,764 houses (93 percent of the 26,562 houses targeted), protecting a total of 106,450 people;

• Training of 309 local personnel to conduct and oversee spray operations; and

• Community education campaigns that included house-to-house visits by 125 community mobilizers as well as a one-day orientation for 703 village chiefs and volunteers to promote support for and acceptance of the IRS campaign.

Malaria in Pregnancy In Years 1 and 2, PMI assisted the Ministry of Health (MOH) to identify potential solutions to address the low uptake of second doses of intermittent preventive treatment for pregnant women (IPTp). This included retraining OLF/USAID health workers, disseminating IPTp job aides, providing TE WKA materials to facilitate directly observed treatment, and A spray operator prepares his pump prior to a day of spraying in developing communications materials for both health staff Malawi. The pesticide, lambda-cyhalothrin, which is both safe and effective, kills mosquitoes that land on walls that have been and patients to increase understanding of the importance of sprayed, reducing the transmission of malaria. receiving at least two doses of IPTp. During Year 2, PMI:

29 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov BOX 1 Decline in Anemia in Children in Nkhotakota District, Malawi

Surveys conducted in Nkhotakota District in 2007 and 2008 show a relative reduction of 28 percent in anemia, which is closely associated with malaria infections, in children 6 to 30 months. A closer look at areas in Nkhotakota District, where PMI supported IRS in October–November 2007, shows an even more dramatic 44 percent reduction in the prevalence of anemia. In light of such positive results, the MOH plans to scale up IRS in six additional high-risk districts. Representatives from those six districts par ticipated in the 2008 spray round in Nkhotakota District to help them understand the best practices and common pitfalls of managing large-scale spray campaigns. The investment in Malawi’s capacity to implement IRS will aid the countr y in moving forward with this life-saving malaria control intervention.

• Procured 4,501,740 ACT treatments and distributed 3,579,278 treatments to health facilities;

• Provided funding for training of 5,315 health workers on case management with ACT;

• Continued to provide technical assistance related to supply chain management that focused on improving the quality and flow of drug utilization data to improve drug management and facilitate decision-making;

• Supported efforts of Malawi’s Pharmacy, Medicines and Poisons Board to regulate drug quality in the private sector; and

• Supported IEC and behavior change communication campaigns at the national and community levels through mass media and interpersonal communication. Messages focused on prompt and effective treatment with an ACT within 24 hours of onset of fever for children under five.

Monitoring and Evaluation PMI is working with the NMCP and other partners to establish and strengthen sentinel malaria surveillance sites in eight districts and to conduct household malaria PSI surveys in eight districts. Data collected during these This packaging for a Malawian ITN tells users that to protect surveys include ITN ownership and usage, treatment of themselves from malaria they should remember that (1) mosqui- fevers in children under five years, and anemia and para- toes that transmit malaria bite at night; (2) pregnant women and children under five are most at risk of malaria; (3) they should sitemia for children 6 to 30 months of age. These sleep under a net every night, all year round; and (4) pregnant surveys have shown a striking reduction in malaria and women and children under five should always be given priority anemia with the scale-up of IRS and ITNs. to use the net.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 30 MOZAMBIQUE FIGURE 3.2 Allocation of $19.8 Million Malaria in Mozambique PMI Budget in Mozambique, FY08 Mozambique has a population of approximately 21.5 (Proportion of budget spent on commodities: 58%) million, and most live in areas where malaria is transmitted. A 2007 Malaria Indicator Survey showed malaria infections in almost 40 percent of children under five and in 16 percent of pregnant women. According to the MOH, 40 percent of all outpatient visits and 60 percent of all pediatric hospital admissions result from malaria.

Insecticide-Treated Nets Mozambique’s major approaches to ITN distribution are subnational campaigns directed at children under five and antenatal clinics to reach pregnant women. During Year 2, PMI:

• Provided technical support to the NMCP, which resulted in a new national policy that aims for universal coverage with long-lasting ITNs (i.e., at least two long-lasting ITNs per household);

PMI RESULTS IN MOZAMBIQUE1 Year 1 Year 2 Cumulative Intervention Indicator (2007) (2008) Results ITNs procured 786,000 720,000 1,506,000 (distributed) (565,000) (842,802) (1,407,802)

Insecticide-Treated ITNs procured by other partners 0 78,0002 78,000 Nets and distributed with PMI suppor t

ITNs re-treated with insecticides 454,986 0 454,986

Spray personnel trained 1,190 1,282 –

Indoor Residual Houses targeted 603,8623 435,550 – Spraying (% sprayed) (97%) (95%)

People protected 2,593,949 1,457,142 –

Health workers 174 422 – trained in ACT use

Diagnosis Health workers trained 391 0 391 and Treatment in malaria diagnostics

ACT treatments procured 1,440,000 3,525,120 4,965,120 (distributed) (220,230) (1,440,000) (1,660,230) BUDGET: $6.3 million (FY06 jump start funds), $18 million (FY07), $19.8 million (FY08)

1 PMI measured Year 1 and Year 2 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. 2 These ITNs were procured by PEPFAR. 3 IRS results for Year 1 are for the complete spray round that took place from October 2007 to February 2008. These numbers are therefore higher than those previously reported in PMI’s Second Annual Report.

31 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov • Procured 720,000 long-lasting ITNs and distributed million treatments were distributed to health facilities. them for free as part of a subnational integrated The remainder of these drugs will be used for the launch measles, vitamin A, deworming, long-lasting ITN of a new malaria treatment policy in March 2009, when campaign in Nampula Province; AL will become the first-line treatment. In addition, PMI provided emergency support for delivery of AL to • Distributed 75,998 free ITNs through antenatal provincial warehouses when the MOH had an unexpect- clinics and another 46,804 free ITNs through other ed shortfall of resources for distribution. PMI continues channels (procured in 2007); and to support pharmaceutical management strengthening of the Central Medical Stores, including support for fore- • Supported the distribution of 78,000 long-lasting casting drug needs and improved tracking of drug ITNs, procured by the U.S. President’s Emergency consumption. Fund for AIDS Relief (PEPFAR), through HIV treatment clinics and outreach activities directed at PMI supported the development of a training curricu- orphans and vulnerable children. lum for health workers and trained 422 workers during a pilot study to identify the most efficient method for dis- Indoor Residual Spraying tribution of AL, which, because of the package size, For the second year in a row, the NMCP requested cannot fit in the standard drug kits shipped to health PMI’s support for IRS activities in six districts in facilities. In addition, a new policy and revised training Zambézia Province. In consultation with the NMCP and material for diagnostic testing of malaria are being final- provincial health authorities, it was agreed that this year, ized with assistance from PMI. more easily accessible houses would be sprayed, whereas houses located in more remote areas would be targeted for long-lasting ITN distribution. This accounts for the lower number of houses targeted for IRS during the second round of IRS. In Year 2, PMI:

• Conducted one round of IRS from September to November 2008, during which 412,923 houses were sprayed (95 percent of the 435,550 houses targeted), and 1,457,142 people were protected; and

• Trained 1,282 local personnel to conduct and supervise spraying.

Malaria in Pregnancy With PMI technical and logistical support, a national health facility survey was conducted in December 2008. This survey evaluated antenatal care and qualitatively assessed the status of, and barriers to, IPTp. Results of the survey should be available in the second quarter of 2009. In collaboration with the MOH, PMI and PEP- FAR staff are implementing an integrated package of services for antenatal visits. This package will include IPTp, long-lasting ITNs, services to prevent mother-to- JONES/USAID child transmission of HIV and sexually transmitted AREBECC diseases, and tuberculosis evaluation and treatment. As part of a combined measles, vitamin A, deworming, and long- Diagnosis and Treatment lasting ITN campaign in Nampula Province, 800,000 children received long-lasting ITNs, of which 720,000 were supplied by In 2008, PMI procured more than 3.5 million treatments PMI. This family received three long-lasting ITNs – one for each of artemether-lumefantrine, the current second-line immunized child. malaria treatment in Mozambique, and a total of 1.44

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 32 BOX 2 Decline in Malaria Prevalence in Zambézia Province, Mozambique

In 2007, at the request of the NMCP, PMI helped expand and strengthen the government’s IRS program in Zambézia Province in Mozambique. With PMI support, a total of 586,568 houses were sprayed (97 percent coverage), and more than 2.5 million people were protected. Then, between September and November 2008, PMI supported a second round of IRS, during which 412,923 houses were sprayed (95 percent coverage), and more than 1.4 million people were protected. Fewer houses were sprayed in the second round because less accessible houses were targeted for long-lasting ITN distribution. In addition, PMI has supported the scale-up of long-lasting ITNs and improved access to ACTs for treatment of malaria throughout Mozambique, including in these six districts. An independent survey, funded by the Bill and Melinda Gates Foundation, carried out in November 2008 in the same six districts, showed a malaria prevalence of 22 percent using rapid diagnostic tests. This represents a 38 percent decline in estimated malaria prevalence when compared with results of a similar 2007 survey carried out by the Innovative Vector Control Consortium. Data courtesy of M. Coleman, Innovative Vector Control Consortium. Data sources: Ministry of Health, Mozambique; Medical Research Council, South Africa; Instituto Nacional de Estatistica Geografica, Mozambique.

Monitoring and Evaluation This survey will collect information on key household- With PMI support, two sentinel sites are functional and and individual-level PMI outcome indicators, including collecting data on both outpatient and inpatient malaria ITN ownership and use of ITNs and IPTp. In 2008, cases and deaths; four more sites are scheduled to com- PMI provided partial financial support to an anemia and mence data collection in 2009. PMI also provided parasitemia survey in six districts in Zambézia Province, technical support to a national AIDS Indicator Survey, which demonstrated a reduction in malaria burden (Box 2). to be implemented in early 2009 with PEPFAR funding.

33 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov RWANDA • Supported a study to examine determinants and barriers to long-lasting ITN ownership and use; final Malaria in Rwanda analysis of the data is in progress. With a population of 9.5 million, Rwanda is one of Africa’s most densely populated countries. Its entire Indoor Residual Spraying population is at risk of malaria. Recent data indicate To complement the distribution of long-lasting ITNs, that malaria transmission has decreased substantially the NMCP uses IRS in targeted high-risk areas. With since 2005–2006. Reported malaria illnesses seen at PMI’s assistance in 2007, more than 159,000 houses health facilities have declined, from 1.5 million in 2005 were sprayed in three districts. In Year 2, PMI: to 900,000 in 2007. • Supported spraying in high-risk sectors of five districts Insecticide-Treated Nets that covered 189,756 houses and protected 885,957 The NMCP aims to achieve 90 percent coverage of all residents. Ninety-four percent of the 201,545 houses age groups with ITNs. The recently revised strategy pro- targeted for spraying were successfully sprayed; motes one long-lasting ITN for every two people or three nets per household. Routine distribution of nets • Provided support for the recruitment and training of occurs at antenatal clinics and vaccination sites through 2,451 spray operators to conduct and oversee operations; social marketing in the commercial sector and community organizations. Preliminary results from the interim • Raised awareness about IRS operations and the need 2008 Demographic and Health Survey showed that 57 to cooperate with spray teams within communities by percent of households owned at least one ITN and 58 training more than 3,000 community members as percent of children under five and 62 percent of preg- information, education, and communication imple- nant women had slept under an ITN the previous night menters; and (Box 3). In Year 2, PMI: • Provided technical assistance to the NMCP to build • Procured 550,000 long-lasting ITNs for free distribu- capacity to conduct entomological monitoring. tion to the poorest households in early 2009; and

PMI RESULTS IN RWANDA1 Year 1 Year 2 Cumulative Intervention Indicator (2007) (2008) Results 550,000 Insecticide-Treated ITNs procured (distribution 0 550,0002 Nets (distributed) planned for early 2009) Spray personnel trained 655 2,451 – Indoor Residual Houses targeted 165,098 201,545 – Spraying (% sprayed) (96%) (94%) People protected 720,764 885,957 – Health workers trained 250 436 – Malaria in in IPTp Pregnancy SP treatments procured 583,333 583,333 0 (distributed) (583,333) (583,333) Health workers 5,127 8,565 – Diagnosis trained in ACT use and Treatment ACT treatments procured 715,000 0 715,000 (distributed) (0) (411,788) (411,788) BUDGET: $1.5 million (FY06 jump start funds), $20 million (FY07), $16.8 million (FY08) 1 PMI measured Year 1 and Year 2 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. 2 As a result of changes in packaging, this shipment of 550,000 ITNs was procured in Year 2 (December 2008) and not Year 1 as previously reported in PMI’s Second Annual Report.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 34 FIGURE 3.3 • Supported the training of 436 health workers to Allocation of $16.8 Million improve the quality of integrated focused antenatal PMI Budget in Rwanda, FY08 care, a package of preventive measures to promote (Proportion of budget spent on commodities: 32%) healthy pregnancies; and

• Procured a one-year supply of iron and folic acid (20 million tablets) to cover the annual need for all pregnant women in preventing anemia.

Diagnosis and Treatment Artemether-lumefantrine, an ACT, is Rwanda’s first-line treatment for uncomplicated malaria. With the fall in malaria prevalence, the NMCP now recommends laboratory confirmation of all cases before treatment. PMI efforts have focused on prompt and effective case management of malaria in health facilities, the private sector, and at the household level through community-based management. In Year 2, PMI:

• Distributed 411,788 ACT treatments procured in Year 1 to health facilities and community health workers, Malaria in Pregnancy and through the commercial sector; Because of decreasing malaria prevalence and increasing parasite resistance to sulfadoxine-pyrimethamine in • Supported community-based treatment of malaria in Rwanda, the NMCP has decided to discontinue IPTp. 10 of 19 malaria-endemic districts in the country; In keeping with the new NMCP policy, PMI continues to support other aspects of prevention and treatment of • Supported repackaging of ACTs for use at the commu- malaria in pregnancy. In Year 2, PMI: nity level and in the private sector to ensure recognition

BOX 3 Decline in Malaria Prevalence and Childhood Mortality in Rwanda

In Rwanda, support from PMI, the Global Fund, and other donors for a strong malaria control effort, led by the NMCP, is producing striking reductions in malaria burden. Preliminary results of a 2008 interim nationwide Demographic and Health Survey show about a fourfold increase in ownership of one or more ITNs, from 13 to 57 percent, and in the proportion of children under five sleeping under an ITN, from 15 to 58 percent between 2005 and 2008. This increased ITN ownership and use, along with targeted IRS, and the rollout of ACTs at both the health facility and community levels, was associated with a fall in the prevalence of malaria to less than 3 percent and an overall reduction in under-five childhood mortality of 32 percent between 2005 and 2008 (from 152 deaths per 1,000 live births to 103 deaths per 1,000 live births). The U.S. Government has been supporting malaria control efforts in Rwanda since 2002, including $1.5 million in PMI jump star t funding in FY 2006 and $20 million in FY 2007.

35 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Rolling Out ACTs in the Private Sector in Rwanda

John and Lydia Munkotanyi live in Rwanda with their five- year-old son Isaac, who has suffered from malaria many times. The last time Isaac had malaria John took him to a private clinic, where the doctor told them about PRIMO, the local brand name for a new ACT antimalarial treatment, artemether-lumefantrine (AL), for children under five years of age. Rwanda converted to AL as the first-line antimalarial treatment in 2006 and rapidly scaled up access in health facilities, but this did not benefit the 40 per cent of patients

who were treated by community health workers and the R AANDWPSI private sector. AL was available in only 6 percent of Rwanda’s pharmacies, primarily in the capital, and at an average price of $8.10 per treatment, it was priced well Isaac Munkotanyi (center), who has suffered from malaria above what most Rwandans could afford to pay. If Rwanda many times, recovered quickly after being treated with the was to achieve its goal of treating 80 percent of childhood ACT artemether-lumefantrine, marketed under the brand name PRIMO. Isaac’s parents obtained PRIMO at a subsi- fevers with an effective ACT within 24 hours, Rwanda dized price though a private pharmacy in Rwanda. needed to make AL more readily available. The NMCP, with support from PMI, made AL available through private sector pharmacies nationwide at a subsidized price of $0.55. A protective envelope for the drug with pictures and information in the local language was de veloped and launched under the brand name PRIMO. The innovative protective envelope provides low-literacy consumers with instructions they can understand and encourages correct and prompt treatment of childhood fevers. PMI worked with the NMCP and the national Pharmacy Task Force to train pharmacy staff as a pr econdition for accessing PRIMO at subsidized prices. Sales were supported by behavior change communication activities that described the symptoms of malaria, appropriate treatment-seeking behavior, and PRIMO as the most effective drug for the treatment of uncomplicated malaria. With more than 60,000 PRIMO treatments sold to private sector pharmacies in 2008, access to AL increased significantly. According to John, “The doctor told us all about PRIMO and ho w we could find it in the pharmacy near our home . We were surprised to find it there at an inexpensive price. After three days, Isaac was completely better; he regained his appetite quickly and, since then, we have told people in our village about PRIMO . The next time a child has a f ever, we know we can treat it quickly with PRIMO, which is easy to find!”

and compliance among caretakers and to permit track- • Funded a national health facility survey that showed ing of facility versus community treatments; and that although 86 percent of facilities surveyed had antimalarial drugs available, the capacity to examine • Assisted with the development of national guidelines blood smears for malaria is available in only about and a standardized curriculum for training of health one-third of facilities; and workers in monitoring of adverse drug reactions to ACTs. • Supported training for ten district-level health officials Monitoring and Evaluation and four province-level NMCP coordinators, which The NMCP has developed a national malaria monitor- included instruction in principles of vector control, ing and evaluation plan, linked with the broader MOH treatment and prevention of malaria at the clinic and monitoring and evaluation strategy. During Year 2, PMI: community levels, and monitoring and evaluation for malaria programs. • Supported verbal autopsies linked with the 2008 interim Demographic and Health Survey to measure malaria-specific mortality;

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 36 SENEGAL • Procured 790,000 long-lasting ITNs and distributed 792,951 nets (including some nets procured in Year Malaria in Senegal 1). Of these: All of Senegal’s population of 11.6 million are at risk of malaria. Historically, malaria has been reported to be - 678,556 were distributed for free to young children responsible for about one-third of outpatient consulta- in five regions participating in the MOH’s tions and one-quarter of deaths among hospitalized micronutrient supplementation days, together with children under five. an additional 69,444 that were distributed to vulnerable populations after the campaign; Insecticide Treated Nets - 42,000 were distributed to children under five and A key malaria prevention strategy of Senegal’s NMCP is pregnant women in four districts of Dakar region the distribution of long-lasting ITNs to pregnant women that experienced heavy flooding in September 2008; and children under five. During its first two years of implementation, PMI has supported a comprehensive - 2,000 were distributed to people living with strategy to increase household ownership and use of HIV/AIDS through regional networks; and ITNs. In Year 2, PMI: - 951 were distributed to other beneficiaries through Peace Corps volunteers.

PMI RESULTS IN SENEGAL1 Year 1 Year 2 Cumulative Intervention Indicator (2007) (2008) Results ITNs procured 200,000 790,000 990,000 (distributed) (196,872) (792,951) (989,823) ITNs sold with PMI marketing 158,060 57,832 215,892 Insecticide-Treated support Nets ITN vouchers redeemed 134,413 168,206 302,619

ITNs re-treated with insecticides 125,632 0 125,632

Spray personnel trained 275 706 – I: 34,8022 Houses targeted 172,0202 (97%) – Indoor Residual (% sprayed) (98%) II: 162,439 Spraying (95%) I: 135,661 People protected 678,971 – II: 645,346

Malaria in Health workers trained 43 2,422 – Pregnancy in IPTp Health workers 1,0203 4,7763 – Diagnosis trained in ACT use and Treatment Health workers trained 0 90 90 in malaria diagnostics BUDGET: $2.2 million (FY06 jump start funds), $16.7 million (FY07), $15.8 million (FY08)

1 PMI measured Year 1 and Year 2 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. 2 For these spray rounds, the number of houses is an estimate based on the number of households reported as sprayed because the definition for “structure sprayed” changed between rounds. 3 In addition, 127 health workers were trained on ACT stock management procedures during Year 1 and 123 in Year 2.

37 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov FIGURE 3.4 through a voucher program that guarantees low-cost Allocation of $15.8 Million nets to vulnerable groups. Under this system, health PMI Budget in Senegal, FY08 committees at participating facilities negotiate agree- (Proportion of budget spent on commodities: 40%) ments with private sector distributors to stock and sell nets through the health facility’s pharmacies, and PMI reimburses the distributors a fixed amount for each net sold; and

• Provided support to commercial ITN vendors for developing marketing plans, recruiting new commercial partners, and producing billboards, television, and radio spots, which resulted in retail sales of 57,832 full-cost long-lasting ITNs to the general public.

To ensure high rates of net demand and use, PMI also invested in information, education, and communication and behavior change communication activities. For example, the well-known Senegalese actor Serigne Ngagne and his drama troupe participated in a “caravan” to distribute subsidized long-lasting ITNs in areas with poor access to nets. At each stop, the drama troupe let residents know that long-lasting ITNs were being distributed and where • Distributed 168,206 long-lasting ITNs at a subsidized they could get them. Skits and health promotion sessions price to pregnant women and children under five in educated the population about the benefits of using long- 550 health facilities in 38 of the country’s 63 districts

Reaching Villagers in Senegal with Malaria Interventions

“In 2006, during the rainy season, we lost seven children from malaria,” said Momath Cissé, chief of the village of Keur Aly Samba. “But after the people sprayed our houses last year, not one child died during the rains.” The village of roughly 1,600 people is located in the district of Nior o du Rip, one of the three districts where PMI is supporting IRS for the prevention of malaria. In 2007, nearly 30,800 households were sprayed, representing more than 99 percent of the 31,000 households approached by the spray teams in the district, and almost 276,000 people were protected. Keur Aly Samba also benefits from a community health hut supported by PMI, where a community health worker provides treatment for malaria, respiratory infections, diarrhea, and tuberculosis; a birth attendant helps with antenatal care and the delivery of babies. Severe malaria cases have to be referred to the closest health post, Y/CDC which requires the health committee and the villagers to PERRTBEROR pay for transportation and medications. Keur Aly Samba’s community health worker noted that in 2006, “We had Children of Keur Aly Samba village stand with their village to send more than 20 children to the health post” for chief, Momath Cissé. PMI’s support of IRS helps protect them from malaria, which caused the deaths of seven children treatment of severe malaria, but in 2007, “Only a handful in 2006. had to be referred.”

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 38 Mosquito Nets Make All the Difference in Thiobe, Senegal

“Last year, during the peak season, I saw 584 cases of malaria,” says the chief nurse at the Thiobe health post in the Diourbel region of Senegal. “This year, there have only been 104. This is the difference that having mosquito nets makes.” Malaria has practically disappeared from this village of approximately 1,000 people, in the heart of Senegal’s millet basin. A trained birth attendant at the health post noted that “There is hardly any malaria this year. We can be at the health post all day and only see maybe one case.” Thiobe benefited from a PMI-supported mass distribution of long-lasting ITNs, in conjunction with the MOH’s local micronutrient supplementation days. More than 700,000 children ages 6 to 59 months in fiv e regions received a free long-lasting ITN, in addition to vitamin A and deworming medication, during the campaign in June 2008, just prior to the star t of seasonal rains and the peak malaria transmission season. Marietou Sarr says that she sleeps under the net e very night with her 11-month-old baby, Ndeye Maty. There haven’t been any cases of malaria in her household this year, a marked difference from last year. She is grateful DEBBIE GUEYE/USAID SENEGAL to have the net, a sentiment echoed by the village chief. Marietou Sarr and her 11-month old baby, Ndeye Maty, received a long-lasting ITN through a recent campaign that “Giving bed nets to all the y oung children in the village was supported by PMI. has really helped us. We won’t forget this.”

lasting ITNs, especially for vulnerable groups, and the • Supported training of 706 local personnel to conduct correct way to wash long-lasting ITNs. and oversee spray operations;

Indoor Residual Spraying • Funded an information campaign that included train- In 2007, PMI funds supported Senegal’s first large-scale ing 800 outreach workers and 582 community leaders IRS campaign in the districts of Vélingara, Nioro, and on IRS promotion and organization; and Richard Toll, each district representing one of the country’s three ecological zones. During Year 2, PMI: • Established a steering committee in each district to mobilize community groups, increase public support • Sprayed an estimated 33,915 houses in Richard Toll for IRS and collaboration among partners, and more during March–April 2008 (97 percent of the 34,802 effectively resolve IRS refusals. Peace Corps volunteers houses targeted), which protected 135,661 people; played a key role in supervision and community mobilization for this activity. • Sprayed a total of 153,942 houses in the same three districts as in Year 1 (Vélingara, Nioro, and Richard Malaria in Pregnancy Toll) during June–August 2008, achieving 95 percent With the efforts of PMI and other partners, IPTp is now coverage among the 162,439 houses targeted for being administered in all MOH antenatal service delivery spraying and protecting 645,346 residents; sites nationwide (all sulfadoxine-pyrimethamine needs are being met by the Government of Senegal). In Year 2, PMI:

39 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov • Supported training for 2,422 health care workers in IPTp; • Trained 70 laboratory technicians and 20 supervisory staff on malaria laboratory diagnosis using the updat- • Provided funding that has enabled health post workers ed curriculum, and purchased 86 microscopes to provide malaria in pregnancy services, including (including three teaching microscopes) and related IPTp, during their regular outreach visits to the supplies; and community-based health huts; and • Supported refresher training in case management for • Purchased and distributed water filters and reusable 2,127 facility health care workers and 2,649 commu- cups to facilitate directly observed treatment for IPTp. nity health workers.

Diagnosis and Treatment Monitoring and Evaluation Since October 2007, the NMCP has required confirma- To measure interim coverage of key interventions, PMI tory testing of all suspected cases of malaria. For and the NMCP supported a nationwide Malaria Indicator inpatients, this testing is through microscopy, while in Survey, including anemia and parasitemia biomarkers, in outpatient facilities, rapid diagnostic tests are used. Case October–November 2008. Preliminary results from this management with ACTs is currently available in all pub- survey will be available in April 2009 and are expected to lic health facilities. During 2008, with the help of PMI, show a significant improvement in nationwide coverage treatment with ACTs at the community level was rolled of ITNs, ACTs, and IPTp when compared with the out to all 1,297 health huts nationwide. As a result, baseline Malaria Indicator Survey of 2006. more than 56,000 children under five were treated pre- sumptively for malaria with ACTs at these health huts. The NMCP also has a strong system of routine collection On World Malaria Day 2008, the Minister of Health of surveillance and program-related data for monitoring announced that co-payments for ACTs would be cut in and evaluation of program performance between surveys. half, and, as a result, dosage packs are now sold for 150 This system relies on quarterly district-level review meet- CFA for children (approximately $0.36) and 300 CFA ings using a standardized reporting form. In Year 2, PMI for adolescents/adults (approximately $0.72). PMI con- resident advisors participated in the quarterly reviews tinues to advocate that ACTs should be free for children and served on a commission charged with improving under five. Through its Round 4 and 7 Global Fund data collection procedures for the reviews and the quality grants, the NMCP is able to meet all public sector needs of the feedback given to districts. Simple feedback tools for ACTs through 2012. During Year 2, PMI: developed by this commission, with support of PMI advisors, have led to improved program performance. • Supported the development of a new training curricu- For example, analysis of first-quarter data showed signifi- lum for malaria laboratory diagnosis, together with a cant overprescription of ACTs in relation to rapid revised system of supervision, quality assurance, and diagnostic test-confirmed malaria cases. Districts took quality control; steps to address the situation, and, by the third quarter, the overuse had been greatly reduced.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 40 CHAPTER 4

“President Boni Yayi's leadership has been a major factor in the success of the aggressive and comprehensive malaria intervention strategy in Benin. He has demonstrated that when leaders are committed to their people, lives will be saved; market places will flourish, and communities will benefit.” – Rear Admiral R.T. Ziemer USN (Ret.), U.S. Global Malaria Coordinator

BENOIST MATSHA-CARPENTIER/VESTERGAARD FRANDSEN A young girl in Benin carries an ITN her family received as part of a national campaign to which PMI contributed ITNs and technical support. Children under five years of age are part of the most vulnerable population because they have not built up resistance to malaria parasites.

41 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov BENIN

Malaria in Benin Benin has a population of approximately 8.3 million, all of whom live in areas where malaria is transmitted. Malaria is a leading cause of morbidity and mortality among children under five and accounts for 44 percent of all outpatient visits and 40 percent of hospitalizations. Benin is a low-income country and ranked 161 out of 179 countries on the 2008 United Nations Human Development Index; almost one-third of the population lives below the poverty line.

Insecticide-Treated Nets (ITNs) Benin’s National Malaria Control Program’s (NMCP’s) strategic plan for 2006–2010 emphasizes ITN use by pregnant women and children under five. The NMCP supports a multipronged approach to net distribution, including free distribution via campaigns, routine visits to vaccination and antenatal clinics, and the commercial sale of nets. PMI supports these activities as well as the

BENIN AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Pregnant women who slept 20%2 under an ITN the previous night 221,000 ITNs procured 385,697 ITNs procured Children under five who slept (215,627 distributed) (45,840 distributed) 20%2 under an ITN the previous night

Houses in geographic areas tar- No areas 142,814 houses sprayed – geted for IRS that were sprayed targeted3 and 521,738 people protected

Women who completed a preg- 605 health workers trained in IPTp nancy in the last two years and 1,267 health workers trained <1%2 who received two or more doses 766,666 SP treatments procured and in IPTp of IPTp during that pregnancy in-country

605 health workers trained in ACT Children under five with use and malaria diagnostics suspected malaria who received 1,465,170 ACT treatments procured <1%2 326,544 ACT treatments ACT treatment within 24 hours (153,884 distributed to health facilities) distributed to health facilities of onset of symptoms 178,400 RDTs procured 104,585 RDTs distributed (73,815 distributed to health facilities) to health facilities

BUDGET: $3.6 million (FY07 jump start funds) and $13.8 million (FY08) 1 PMI measured jump start and Year 1 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. The table includes USG-funded malaria jump start activities that took place in 2007 (reported in PMI’s Second Annual Report) and PMI 2008 activities. 2 Source: 2006 Benin Demographic and Health Survey. ACTs were adopted in November 2004, but national rollout of ACTs only began in August 2008. 3 At baseline, no areas were targeted for spraying by the National Malaria Control Program.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 42 FIGURE 4.1 • Provided support for training 335 local residents to Allocation of $13.8 Million conduct IRS and supervise operations; PMI Budget in Benin, FY08 (Proportion of budget spent on commodities: 42%) • Supported a successful round of spraying in four communes (Sèmè-Kpodji, Adjohoun, Dangbo, and Akpro-Missérété), during which 142,814 houses were sprayed (94 percent of targeted houses), and 521,738 people were protected;

• Informed communities about IRS through 150 community mobilizers and five community radio stations. In addition to door-to-door visits to all households in the communities, activities included local skits and interviews, four music concerts, distribution of 110,046 leaflets, 1,335 radio spots, 20 debates, and 575 radio shows on IRS; and

• Collaborated with entomologists at the Centre de Recherche Entomologique de Cotonou (CREC), an indigenous research institution, to develop and imple- Note: In addition to FY08 funding, $3.6 million of FY07 funds ment an IRS monitoring and evaluation plan. The were also used: $1,256,667 for ITNs; $271,917 for IRS; plan included the routine capturing of mosquitoes to $697,038 for malaria in pregnancy activities; and $1,374,346 for monitor vector species and densities, setting up mos- diagnosis and treatment activities. quito traps inside and outside dwellings to monitor vector behavior change, conducting World Health Organization wall cone bioassays to assess insecticide sale of highly subsidized, socially marketed nets. PMI’s decay rate, and collecting Anopheles gambiae larvae in support of social marketing activities reinforces existing different locations of the IRS area to determine and private sector ITN distribution channels by hosting track resistance among mosquitoes. wholesalers’ meetings, identifying rural sales points, and training retailers. Since Benin became a focus country in December 2006, PMI has:

• Procured 606,697 long-lasting ITNs (including 2007 and 2008 procurements) and distributed 261,467 through a variety of channels, including health facilities, the commercial sector, and a national campaign; and

• Contributed 150,000 long-lasting ITNs and technical support for a national campaign in October 2007, during which a total of 1.7 million nets were distributed.

Indoor Residual Spraying (IRS) During 2008, in partnership with the Government of Benin and local communities, PMI supported one round

of IRS in four communes in the Ouémé Department in USAID BENIN southern Benin. This was the first large-scale IRS program At Cotonou-Port, Benin, a soldier stands guard over containers of 280,000 long-lasting ITNs procured by PMI in 2008. PMI is in Benin in 30 years. Due to high levels of pyrethroid working with the NMCP to increase use of ITNs among preg- resistance, a nonpyrethroid insecticide (bendiocarb) was nant women and children under five. used. As part of the IRS campaign, PMI:

43 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Women Pioneer Antimalaria Efforts in Benin

Diane Sagbohan is one of only six female spray operators among the 265 spray operators who participated in Benin’s first IRS campaign in three decades. Diane is from Sèmè-Kpodji, one of the four communes selected for spray operations during 2008 and known for high rates of malaria transmission. Diane, a 23-year-old mother of a two-year-old boy, works as a clerk typist. Despite the fact that spray operators for IRS campaigns are mostly men from her community, she was eager to join this effort against malaria. When asked what motivated her to become a spray operator, Diane responded that it was an exceptional oppor tunity to participate in the fight against malaria, the most common disease in her village and the disease that most people die from. “I feel valued and useful to my community by taking part in the IRS campaign,” she stated, and concluded that she was “motivated and ready to participate in the next campaign.” Diane’s participation in the IRS campaign opens a ne w social dimension for female leaders in combating malaria in Benin. In her community, she is viewed as a pioneer and an example for others to change their behavior and adopt

practices to prevent malaria. The participation of Diane IRT and other women will help raise awareness about malaria Diane Sagbohan is one of a handful of female spray operators and induce behavior change in their communities. who are contributing to IRS operations in Benin. Prior to PMI, few countries in Africa were conducting large-scale IRS campaigns. Diane participated in one of the first campaigns in Benin in 30 years.

least one ANC visit, according to the 2006 Demographic Insecticide Resistance and Health Survey), only 3 percent reported receiving the Because resistance to pyrethroid insecticides (used on recommended two doses of sulfadoxine-pyrimethamine long-lasting ITNs and for IRS) among mosquitoes is (SP) during pregnancy. Since beginning work in Benin, well documented in Benin due to agricultural use, PMI PMI has: has also provided support to CREC to monitor and map mosquito resistance through the establishment of six • Procured 766,666 SP treatments as part of PMI 2007 entomological surveillance sites in various ecological jump start activities, which have arrived in country settings throughout the country. PMI also is supporting and are being distributed to health facilities; focused operations research to better understand how mosquito resistance impacts the effectiveness of • Supported training of 1,201 health workers and 66 pyrethroid-based malaria control measures in Benin. trainers nationwide on how to administer IPTp in 2008, in addition to 605 health workers trained in Malaria in Pregnancy 2007; and Intermittent preventive treatment for pregnant women (IPTp) was introduced nationally in 2005. While atten- • Supported the production of a facilitator and training dance of pregnant women at antenatal clinics (ANCs) is guide for IPTp for the NMCP. high in Benin (88 percent of pregnant women make at

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 44 Diagnosis and Treatment Use of artemether-lumefantrine (AL), an artemisinin- based combination therapy (ACT), as the first-line drug for uncomplicated malaria began in Benin in November 2004, in a small pilot area. Large-scale implementation did not begin until 2008. Under the policy, any child under five years of age with a fever should receive presumptive antimalarial treatment, either at a health facility or at the community level. The World Bank Malaria Booster Program in Benin is covering the bulk of needs for rapid diagnostic tests (RDTs) as well as some of the ACT needs. Global Fund Round 7 funds are being used to implement ACT distribution at the community level. PMI is complementing these efforts through ACT procurement, training for health workers, and support to nongovernmental organizations (NGOs) working at the community level. Since Benin became a PMI focus country, PMI has:

• Procured 1,465,170 ACT treatments (during 2007), which have arrived in country. Of these, 480,428 treatments have been distributed to health facilities;

• Procured and distributed 178,400 RDTs;

• Supported training of 605 personnel in malaria diag- ARPENTIER

nostics and case management with ACTs during 2007; TSHA-C

• Procured 30 microscopes, which are scheduled to BENOIST MA arrive in country in early 2009; Community helpers, wearing armbands, prepare to hand out ITNs during a national campaign in Benin, to which PMI • Contributed to the development of guidelines for the contributed 150,000 long-lasting ITNs and technical support. A total of 1.7 million nets were distributed for free through Integrated Management of Childhood Illness at the this campaign. community level (community IMCI).

• Led discussions with the NMCP, the Department of the World Bank Malaria Booster Program as well as Family Health, donors, and NGOs to map case resources from the national budget. The supervision management activities and select geographic zones for plan will roll out in March 2009. PMI partners to implement community IMCI. The discussions and redistribution of implementation One of the challenges over the coming year will be to zones resulted in national coverage of all 34 health strengthen supply chain management capacity in the zones in the country with either community IMCI National Medical Stores and health facilities to immediately or community-based management of malaria; and reduce stockouts and overstocking of malaria commodities. An evaluation of the governance structure of the central • Provided support to the NMCP to strengthen the drug store was conducted in November– December national supervision system to improve the quality of 2008. PMI is currently engaging in policy dialogue with malaria case management by Ministry of Health staff. the Ministry of Health and other donors to implement With PMI support, the NMCP has developed a con- reforms that will make the central drug store more effective. solidated supervision plan that includes support from

45 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Monitoring and Evaluation A Demographic and Health Survey conducted during 2006 provides baseline data for many PMI indicators. In 2008, PMI:

• Worked with the NMCP to enhance health facility- based surveillance in health zones designated as sentinel sites. Data collection is expected to begin in early 2009.

• Contributed, along with the World Bank Malaria Booster Program, to the NMCP survey in November–December 2008 to assess ITN ownership and use after the October 2007 national campaign of free distribution of long-lasting ITNs to children under five years.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 46 CHAPTER 5

“On World Malaria Day, Americans stand in solidarity with Ethiopia and communities across the globe in the fight against malaria. Today, we commemorate World Malaria Day with you, celebrate your achievements, and rededicate our historic partnership between Ethiopia and the United States to defeat this preventable and treatable killer.” – Glenn Anders, USAID Ethiopia Mission Director, in remarks on the occasion of World Malaria Day, April 25, 2008

BONNIE GILLESPIE/ Children under five are especially vulnerable to malaria. In Ethiopia, where PMI has been working since December 2006, VOICES FOR A MALARIA-FREE FUTURE malaria is characterized by frequent and often large-scale epidemics. To lower infection rates, PMI is working with its partners to increase the use of long-lasting ITNs and the prompt and appropriate treatment for children under five with fevers.

47 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov ETHIOPIA: OROMIA REGION

Malaria in Ethiopia: Oromia Region Historically, malaria has been the leading communicable disease in Ethiopia, with major epidemics every five to eight years. Three-quarters of the country are malarious, and approximately 50 million people live in malarious areas. PMI’s activities in Ethiopia are focused in Oromia Region, the largest and most malarious of Ethiopia’s 11 regions, covering one-third of the country’s landmass. In Oromia, more than 17 million people are at risk of infection, and malaria accounts for 20 to 35 percent of outpatient consultations, 16 percent of hospital admissions, and 18 to 30 percent of hospital deaths.

Insecticide-Treated Nets (ITNs) Ethiopia’s National Strategic Plan for Malaria Prevention and Control has a 2010 target of 100 percent coverage in malarious areas with two ITNs per household. As reflected in recent surveys, ITN and long-lasting ITN ownership has increased dramatically in recent years: In

ETHIOPIA (OROMIA REGION) AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1

Pregnant women who slept 29%2 under an ITN the previous night 102,145 ITNs procured 22,284 ITNs procured and distributed and distributed Children under five who slept 24%2 under an ITN the previous night

316,829 houses sprayed and Provided partial support to 1,000,526 people protected; Houses in geographic areas tar- Not an IRS campaign, which protected and provided partial support geted for IRS that were sprayed available3 3.89 million people to an IRS campaign, which protected 4.92 million people

Children under five with 600,000 ACT treatments suspected malaria who received procured and in-country <1%2 – ACT treatment within 24 hours 2,786 health extension of onset of symptoms workers trained in ACT use

BUDGET: $6.7 million (FY07 jump start funds) and $19.8 million (FY08)

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 48 FIGURE 5.1 training and supervising spray operators; supporting Allocation of $19.8 Million environmentally sound pesticide management; and PMI Budget in Ethiopia (Oromia Region), FY08 monitoring and evaluation. Since Ethiopia joined PMI (Proportion of budget spent on commodities: 46%) in December 2006, PMI:

• Supported spraying of 316,829 houses in Oromia (74 percent of those targeted), providing protection to 1,000,526 residents;

• Purchased 970 spray pumps and spare parts kits, personal protection materials for spray personnel, and other IRS equipment;

• Trained 1,198 local personnel to conduct and supervise spray operations; and

• Provided partial support for IRS campaigns during two successive years. U.S. Government funds were used to procure insecticides, train IRS personnel, and plan, oversee, and monitor IRS operations. This Note: In addition to FY08 funding, $6.7 million of FY07 funds resulted in protection of 3.89 million people in 2007 were also used: $1,146,250 for ITNs; $1,696,250 for IRS; $196,250 for malaria in pregnancy activities; $3,583,250 for and 4.92 million people in 2008. diagnosis and treatment activities; and $78,000 for other malaria activities. Malaria in Pregnancy Because of generally low levels of malaria transmission, intermittent preventive treatment is not part of the Oromia, 41 percent of households own at least one ITN, National Strategic Plan for Malaria Prevention and up from less than 2 percent in 2005. Nets are distributed Control. The MOH and PMI support other activities to through semiannual child health campaigns, routinely at prevent and treat malaria among pregnant women. Since health facilities, and door-to-door. Since Ethiopia beginning work in Oromia, PMI: became a focus country, PMI has:

• Procured a total of 124,429 long-lasting ITNs, which were distributed through health facilities (for free or with a high subsidy) or via the private sector (at a subsidized price);

• Worked with the Ministry of Health (MOH) and partners to develop a National Vector Control Strategy, including strategies for ITN replacement; and

• Supported a comprehensive package of information, education, and communication and behavior change communication activities to increase access to and utilization of long-lasting ITNs.

Indoor Residual Spraying (IRS) PMI extended and strengthened Ethiopia’s long-standing KAMDEN HOFFMANN/USAID A storekeeper reaches for an ITN in Ethiopia. PMI subsidizes the IRS program through a range of activities. This included sale of ITNs in the private sector as one of several ways of improving the targeting of IRS; strengthening procure- increasing net ownership. ment, storage, and distribution systems for commodities;

49 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Diagnosis and Treatment Ethiopia’s national treatment guidelines recommend artemether-lumefantrine (AL) as the first-line treatment for uncomplicated falciparum malaria and chloroquine as treatment for the other three species of malaria parasites. Since December 2006, PMI has:

• Procured 600,000 AL treatments, which will be distributed in early 2009;

• Initiated the conceptualization and design of a quality assurance/quality control system for malaria laboratory diagnosis in health facilities;

KAMDEN HOFFMANN/USAID • Assessed the antimalarial drug management practices Mothers wait with their babies at a clinic in Oromia Region, at health facilities throughout Oromia; and Ethiopia. PMI has targeted this region because it bears the brunt of the country’s malaria burden. • Provided technical and financial support to the Drug Administration and Control Authority to assess the • Supported training for 2,786 peripheral health exten- quality of antimalarial drugs on the market in selected sion workers on malaria case recognition and sites in Oromia. management of malaria in pregnancy; Monitoring and Evaluation • Provided for the distribution of ITNs through antenatal Ethiopia’s recently revised Health Management care clinics; and Information System (HMIS) will measure several malaria indicators that will inform decisions on resource allocation, • Collaborated with the U.S. President’s Emergency Plan program activities, and policymaking at all levels of the for AIDS Relief to support malaria health education health system. During the past year, PMI assisted with activities aimed at increasing antenatal care and sup- the Government of Ethiopia’s rollout of HMIS routine port for the prevention of mother-to-child data collection and analysis and dissemination of data transmission of HIV. from the 2007 Malaria Indicator Survey.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 50 CHAPTER 6

“It is better to prevent malaria, but when you get it, treat it well. Mosquitoes do not need permission to enter your bedroom, nor do they need visas to travel from one community to the other or one district to the other, let alone fly to and from our neighboring countries and beyond. Partnership locally, nationally, and internationally is vital in our bid to conquer malaria.” – Dr. Constance Bart-Plange, National Malaria Control Program Manager, June 2008

RICHARD KAHN/CDC Women from the rural Agona Abodum community in Central Region, Ghana, line up to redeem their vouchers for free ITNs. PMI works with the Government of Ghana to distribute ITNs through multiple channels, including voucher programs such as this one.

51 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov GHANA

Malaria in Ghana Malaria is hyperendemic in all parts of Ghana, with the entire population of 23 million at risk. Malaria is also the number one cause of morbidity in Ghana and is thought to account for about 38 percent of all outpatient illnesses, 36 percent of all hospital admissions, and an estimated 20 percent of all deaths in children under five years of age.

Insecticide-Treated Nets (ITNs) In June 2008, the National Malaria Strategic Plan (2008–2015) was revised to include universal coverage with ITNs for all population groups. Ghana embraces a mixed model for the distribution of long-lasting ITNs, which incorporates multiple approaches: mass free distribution; targeted subsidy programs, including voucher schemes (in 5 of 12 regions); subsidized sales at public clinics (all regions); commercial sales; distribution at the

GHANA AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Pregnant women who 60,023 ITNs 350,000 ITNs procured 2 slept under an ITN 3% procured and distributed 750,000 ITNs distributed4 the previous night 612,000 ITNs sold by 236,789 vouchers redeemed for ITNs Children under five who commercial partners 1,234,159 ITNs sold slept under an ITN 22%3 151,036 nets re-treated by commercial partners the previous night with insecticide 429,213 nets re-treated with insecticide Houses in geographic areas tar- Not 254,305 houses sprayed and 601,973 – geted for IRS that were sprayed applicable5 people protected Women who completed a pregnancy in the last two years and 25%3 – 464 health workers trained in IPTp who received two or more doses of IPTp during that pregnancy

Children under five with 1,142,759 ACT treatments suspected malaria who received <1%3 – procured and being distributed ACT treatment within 24 hours of onset of symptoms 368 health workers trained in ACT use BUDGET: $5 million (FY07 jump start funds) and $16.8 million (FY08) 1 PMI measured jump start and Year 1 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. The table includes USG-funded malaria jump start activities that took place in 2007 (reported in PMI‘s Second Annual Report) and PMI 2008 activities. 2 Source: 2003 Ghana Demographic and Health Survey. 3 Source: 2006 Ghana Malaria Indicator Cluster Survey. 4 PMI helped to distribute these long-lasting ITNs that were procured by UNICEF and the World Bank. 5 No areas were targeted for public sector spray campaigns by the National Malaria Control Program prior to 2008. Since 2004, AngloGold Ashanti has implemented a spraying program in the Obuasi District, site of its gold mine.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 52 FIGURE 6.1 • Re-treated 580,249 nets (2007 and 2008) with insec- Allocation of $16.8 Million ticides for free in three regions. This ambitious mass PMI Budget in Ghana, FY08 re-treatment campaign, which exceeded its targets, was (Proportion of budget spent on commodities: 41%) conducted in collaboration with local NGOs and a network of community volunteers. In 2009, PMI will discontinue the net re-treatment program and will replace old nets with new long-lasting ITNs; and

• Provided technical assistance to the National Malaria Control Program (NMCP) to develop a database system to track ITN distribution through all channels in Ghana.

A 2008 survey carried out by the PMI-funded NetMark Project showed that household ownership of ITNs had increased on average from 11 percent in 2004 to 64 percent in 2008 in five targeted regions, while the proportion of children under five who slept under an ITN increased, from 8 to 41 percent.

Indoor Residual Spraying (IRS) Note: In addition to FY08 funding, $5 million of FY07 funds In recent years, Ghana has moved aggressively to expand were also used: $2,972,500 for ITNs; $72,500 for IRS; $797,500 IRS. Based on the successful experience with IRS by the for malaria in pregnancy activities; $372,500 for diagnosis and treatment activities; and $775,000 for other malaria activities, AngloGold Ashanti mining company, the National including ACT quantification, supply chain strengthening, policy Malaria Strategic Plan was rewritten to incorporate IRS development, and behavior change communication activities at as a key component of an integrated vector control pro- the community level. gram. The national plan calls for rapidly scaling up IRS to protect at least one-third of Ghana’s districts by the end of 2015. community level through nongovernmental organizations (NGOs); and workplace distributions. Since Ghana During 2008, PMI supported the first large-scale imple- became a focus country, PMI has: mentation of IRS in the public sector, in collaboration with the Ghana Health Service. PMI-supported IRS • Procured 410,023 long-lasting ITNs, of which 60,023 operations benefited from technical assistance and col- were distributed in 2007; the remaining 350,000 laboration provided by AngloGold Ashanti, particularly arrived in country in early 2009; in the areas of community sensitization, training of trainers, and training of spray operators. After Ghana • Distributed 236,789 nets (vouchers redeemed) was named a focus country, PMI: through ITN voucher schemes run by the Ghana Health Service; • Supported the spraying of 254,305 houses (94 percent of those targeted), protecting 601,973 people; • Promoted sales of more than 1.8 million ITNs (612,000 in 2007 and 1,234,159 in 2008) by sup- • Funded the training of 468 local personnel to conduct porting partnerships with six commercial ITN and oversee spray operations; and distributors in the private sector through technical assistance, advocacy, and advertising support; • Mobilized community support for spraying through

• Assisted with campaign planning and transportation - stakeholder meetings at the regional, district, and for 750,000 nets purchased by UNICEF and the community levels, targeting political leaders, World Bank as part of a nationwide campaign to administrators, traditional chiefs, women, religious distribute 1.5 million ITNs; leaders, environmental officers, and health workers; - brochures and clubs aimed at schoolchildren;

53 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov - radio spots across the Northern Region to dissemi- nate messages about IRS; and - press and media interviews sponsored by the regional health directorate.

PMI also assisted in the preparation of a successful Round 8 Global Fund grant proposal that includes a $110 million IRS component, to be implemented between 2009 and 2013. The IRS component was designed to build on the AngloGold Ashanti private sector program and lessons learned from the PMI-funded public sector pilot.

Malaria in Pregnancy I GHANATR The NMCP policy recommends three doses of sulfadoxine- An IRS community liaison team crosses a tributary of the Volta River to reach isolated villages in Ghana. Information, education, pyrimethamine for intermittent preventive treatment for and communication programs conducted by such teams prepare pregnant women (IPTp). During Year 1, PMI supported communities for IRS campaigns and increase cooperation with malaria in pregnancy interventions, with a specific focus spray teams. on districts in southern Ghana, where USAID health programs have been supporting 30 of the most under- • Provided technical assistance to strengthen the supply served districts in the country. For example, PMI: chain for antimalarial medications and to promote their rational use by patients, pharmacists, and other • Provided technical and financial support to update the health care workers; and health care worker training curriculum on malaria in pregnant women; and • Supported the further development of the national treatment policy, including the expansion of home • Supported training of 464 health workers in IPTp. management of malaria and the updating of training manuals. Diagnosis and Treatment Artemisinin-based combination therapy (ACT) has been Monitoring and Evaluation Ghana’s first-line treatment for uncomplicated malaria The Ghana Health Service is moving toward a national since 2004. With PMI support, a technical working integrated approach to disease surveillance. As part of group has been charged with developing a policy that this effort, PMI helped the NMCP develop a compre- lays out the role and use of both microscopy and rapid hensive malaria monitoring and evaluation plan. PMI diagnostic tests for diagnosis of malaria and provides a provided support for the 2008 Demographic and Health framework for its implementation. Survey, which will provide baseline coverage for all PMI indicators. PMI also is supporting development of sen- Since Ghana was named a focus country in December tinel sites in various regions of the country that will 2006, PMI: collect routine facility-based data on malaria mortality and morbidity. The data collection protocols and instru- • Carried out a quantification exercise for antimalarial ments have been developed, and sentinel site data for the drugs, which identified a serious threat of a nation- last quarter of 2008 have been collected. wide stockout of ACTs by the end of 2008. With time running short and other funds unavailable, the Ministry of Health made a formal request to PMI to assist in procuring an emergency supply of ACTs. PMI procured 1,142,759 ACT treatments that arrived in November 2008 for distribution to health facilities;

• Supported training of 368 health workers on the proper use of ACTs;

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 54 CHAPTER 7

“The PMI has offered much needed support in the scaling up of critical interventions of the malaria control program in Kenya. The outcome is very promising. In the three districts where PMI supported the scaling up of indoor residual spraying, we are now documenting significant reductions in malaria morbidity, and we plan to make these districts our model districts for effective malaria control.” – Dr. Willis S Akhwale, Head, Department of Disease Prevention and Control, Ministry of Public Health and Sanitation, Kenya

PSI KENYA A distributor hands out ITNs to mothers of young children in Kenya, where nets are provided for free to children under one and pregnant women. Since usage of nets has remained low despite a dramatic increase in net ownership, PMI will continue to support community-based information, education, and communication and behavior change communication campaigns to increase demand for ITNs and their correct usage.

55 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov KENYA

Malaria in Kenya Seventy percent of Kenya’s population of 34 million people are at risk of malaria, including an estimated 3.5 million children under five and 1.1 million pregnant women. Malaria is the leading cause of morbidity and mortality in Kenya. It accounts for about 30 percent of all outpatient consultations, 19 percent of all hospital admissions, and an estimated 34,000 deaths annually among children under five years of age.

Insecticide-Treated Nets (ITNs) The policy of the Government of Kenya is to distribute long-lasting ITNs free to pregnant women at antenatal clinics (ANCs) and to children under one year of age. Since Kenya became a PMI focus country:

• PMI donated 60,000 long-lasting ITNs for the national net re-treatment campaign in October 2008

KENYA AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Pregnant women who slept 33%2 under an ITN the previous night 60,000 ITNs procured – Children under five who slept and distributed3 40%2 under an ITN the previous night Provided partial support 207,370 houses sprayed and 1,257,941 people Houses in geographic areas target- Not to an IRS campaign in 14 protected in three districts; and provided ed for IRS that were sprayed available4 districts, which protected partial support to an IRS campaign in 14 3.4 million people districts, which protected 1.8 million people Women who completed a pregnancy in the last two years and Training materials for malaria 12%2 – who received two or more doses in pregnancy developed of IPTp during that pregnancy 1,281,720 ACT treatments procured Children under five with and distributed to an estimated 4,949 suspected malaria who received 4%2 – health facilities ACT treatment within 24 hours of onset of symptoms 77 laboratory technicians trained in malaria diagnostics BUDGET: $6.1 million (FY07 jump start funds) and $19.8 million (FY08) 1 PMI measured jump start and Year 1 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. The table includes USG-funded malaria jump start activities that took place in 2007 (reported in PMI’s Second Annual Report) and PMI 2008 activities. 2 Source: Kenya Malaria Indicator Survey 2007 – Preliminary data. 3 In PMI’s Second Annual Report, 60,000 ITNs were reported as procured and 5,000 as distributed during 2007. Actual procurement and distribution took place in 2008. Of the 60,000 ITNs, 5,000 were distributed with PMI support and 55,000 were distributed in partnership with DfID. 4 At baseline, the Government of Kenya’s policy was to conduct IRS in epidemic-prone districts only, supported by a Global Fund grant. With PMI’s assistance, it has recently begun to refocus its IRS strategy to endemic areas.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 56 FIGURE 7.1 • Supported training of 1,452 local residents and district Allocation of $19.8 Million health staff to conduct and oversee spraying activities; PMI Budget in Kenya, FY08 (Proportion of budget spent on commodities: 49%) • Supported training of community volunteers who made house-to-house visits to educate residents about the risks of malaria and the value of spraying; and

• Provided partial support for IRS campaigns in 14 districts during two successive years, which protected 3,459,207 people in 2007 and 1,804,026 people in 2008 (when the spray efforts strategically targeted only the highest risk populations). PMI support exceeded $350,000 and included the payment of allowances to spray operators and technical support to the DOMC to train supervisors on planning, implementing, monitoring, and evaluating spray operations.

Malaria in Pregnancy Kenya has integrated prevention of malaria in pregnancy activities into its focused antenatal care program that Note: In addition to FY08 funding, $6.05 million of FY07 funds were also used: $420,000 for ITNs; $3.25 million for IRS; $1.49 promotes overall health of pregnant women. Each year, million for diagnosis and treatment activities; and $892,000 for approximately 1.1 million pregnant women are at risk of other malaria activities, including information, education, and acquiring malaria in Kenya. According to preliminary communication and behavior change communication activities, data from the 2007 Kenya Malaria Indicator Survey, the social marketing, and staffing costs. percentage of women receiving two or more doses of sulfadoxine-pyrimethamine for intermittent preventive to replace nets that were too worn to be re-treated. treatment for pregnant women (IPTp) was only 12 percent PMI distributed 5,000 of these nets directly; the in spite of high ANC attendance rates (52 percent of remaining 55,000 were distributed by the British Department for International Development (DfID). In total, 3 million nets were re-treated in this campaign through a partnership among the Division of Malaria Control (DOMC), the World Health Organization, UNICEF, DfID, and PMI.

Indoor Residual Spraying (IRS) While the Government of Kenya’s policy is to conduct IRS in epidemic-prone districts (supported by a Global Fund grant), it has recently begun to refocus its IRS strategy to endemic areas, particularly those that border the highland districts covered by the existing IRS program. A DIVISION OF MALARIA CONTROL With the support of PMI, Kenya has strengthened its IRS program and expanded into one endemic district. Since the start of its work in Kenya, PMI has: JAMES SANG/KENY Eunice Achieng, with her two-month old son, speaks with Dr. Akhwale, Head of the Department of Disease Prevention and • Supported spraying of 207,370 houses with a synthetic Control. Since her home in Rachuonyo District in western pyrethroid insecticide in three districts (Nandi North, Kenya was sprayed during a PMI-supported campaign, her fami- Nandi South, and Rachuonyo), protecting a total of ly has been free of malaria. Mrs. Achieng’s husband noted that “Mosquitoes were a problem before the spraying, but now there 1,257,941 residents. Ninety-six percent of houses are no mosquitoes.” targeted for spraying were sprayed;

57 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Shedrack Maritim Awarded ‘Spear of Heroism’ for Fighting Malaria

During 2008, PMI protected nearly 400,000 people in the Nandi District, Rift Valley Province, in Kenya through an IRS campaign that sprayed more than 200,000 homes. The district is characterized by hilly terrain and, like many rural areas in Kenya, is home to villages that are often neglected and have difficulty accessing basic health ser vices. With PMI support, motivated teams of spray operators reached these remote areas. Shedrack Maritim is one of the committed spra y operators who is making sure that isolated communities are not A DIVISION OF MALARIA CONTROL overlooked. Carrying a spray pump loaded with 10 liters of insecticide, he trekked more than two kilometers to Chemamul village. Previous spray campaigns, which began JAMES SANG/KENY in the district in 1999, had not reached the village. A After walking more than two kilometers to Chemamul village, Kenya, to take part in an IRS campaign, spray operator Chemamul village elder was so delighted that he honor ed Shedrack Maritim was awarded a “spear of heroism” by a Shedrack with a warrior’s spear for his commitment to grateful village elder. fighting malaria.

women made four or more ANC visits during pregnancy). • Supported, in partnership with DfID, the develop- During the past year, PMI developed materials on ment of materials for a health worker training focused antenatal care and malaria in pregnancy for a program on malaria case management currently wide-scale training program scheduled for 2009. planned for 2009; and

Diagnosis and Treatment • Trained 77 laboratory technicians on malaria In September 2006, Kenya launched artemether-lume- microscopy and parasitological diagnosis to improve fantrine (AL), an artemisinin-based combination therapy malaria diagnostics and case management. (ACT), as its new first-line malaria treatment. In 2008, Kenya experienced difficulties in procuring new supplies Monitoring and Evaluation of AL that, coupled with the postelection violence in In 2008, PMI funding was used to train 26 DOMC 2007–2008, caused extensive stockouts for several program staff to use the Malaria Information Acquisition months into 2008. In response to this crisis, PMI: System, a management tool the DOMC uses to monitor its activities. PMI supported the malaria module of the • Procured and distributed an emergency supply of Kenya 2008 Demographic and Health Survey and analysis 1,281,720 AL treatments to regional depots and health of data from the 2007 Malaria Indicator Survey. These facilities nationwide. PMI expects to continue to pro- two surveys will provide a baseline measure of malaria cure AL to ensure that drug stockouts are minimized; morbidity and mortality, as well as coverage of major interventions in Kenya. PMI also supported develop- • Provided technical support to the Kenya Medical ment of four health facility-based sentinel sites to track Supply Agency and the DOMC to strengthen supply malaria-related morbidity and mortality. chain management and monitor stocks of all malaria medicines. This included quantification of AL and other antimalarial drugs, stock inventory, distribution planning, and monitoring. In addition, PMI supported the development of a national curriculum package that will be used to train staff to manage all malaria medicines;

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 58 CHAPTER 8

“One of the things I'm really proud about in every country that we work in, is the partnerships that develop. The countries design their strategy for approaching malaria, what they're going to do and how they're going to distribute the commodities. We support their plan, and I think that's one of the reasons this program has been so effective, and one of the reasons leaders, like President Johnson Sirleaf, like it so much. It's not just money that comes in – but it's what they want and what they think will help their people the best.” – Rear Admiral R.T. Ziemer USN (Ret.), U.S. Global Malaria Coordinator

NENA TERRELL/USAID LIBERIA Liberians in Tubmanburg, Bomi County, watch the launch of PMI’s ITN campaign in Liberia. ITNs, which have not been widely used in Liberia, are just one of the effective prevention measures PMI is using to reduce malaria- related deaths by 50 percent.

59 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov LIBERIA

Malaria in Liberia Until 2003, Liberia had been in a state of intermittent civil war for more than a decade, and almost all health services were provided by humanitarian assistance groups. With political stability, the Government of Liberia is increasingly taking over the provision of health services. Malaria is endemic throughout Liberia and is a leading cause of morbidity and mortality, with the entire population of approximately 3.5 million at risk. It accounts for more than 40 percent of all outpatient consultations and 18 percent of inpatient deaths.

Insecticide-Treated Nets (ITNs) Prior to the conflict, there was little history of ITN use in Liberia. The National Malaria Control Program’s (NMCP’s) Strategic Plan for 2008–2013 has a target of one long-lasting ITN for each sleeping space, or approximately three per household. To date, the Ministry of

LIBERIA AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Pregnant women who slept Pending2 under an ITN the previous night 197,000 ITNs procured3 184,000 ITNs distributed4 Children under five who slept Pending2 under an ITN the previous night Houses in geographic areas target- No areas – – ed for IRS that were sprayed targeted5

Women who completed a pregnancy in the last two years and Pending2 – 417 health workers trained in IPTp who received two or more doses of IPTp during that pregnancy

Children under five with suspected malaria who received 496,000 ACT 496,000 ACT treatments distributed Pending2 ACT treatment within 24 hours treatments procured 595 health workers trained in ACT use of onset of symptoms BUDGET: $2.5 million (FY07 jump start funds) and $ 12.4 million (FY08)

1 PMI measured jump start and Year 1 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. The table includes USG-funded malaria jump start activities that took place in 2007 (reported in PMI’s Second Annual Report) and PMI 2008 activities. 2 Baseline coverage data will be provided by the 2008 Malaria Indicator Survey, which is currently being conducted. 3 In PMI’s Second Annual Report, 196,000 ITNs were reported as procured. Actual procurement was 197,000. 4 Of the 197,000 nets procured by PMI, 13,000 were stolen from one of the county depots while awaiting distribution to health facilities. PMI and Liberian government authorities conducted a thorough investigation and have proposed corrective measures. 5 At baseline, no areas were targeted for spraying by the National Malaria Control Program.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 60 FIGURE 8.1 of ITNs and intermittent preventive treatment for preg- Allocation of $12.4 Million nant women (IPTp) with sulfadoxine-pyrimethamine PMI Budget in Liberia, FY08 (SP). The SP is free of charge, and health workers are (Proportion of budget spent on commodities: 47%) encouraged to provide cups and water so that they can directly observe patients swallowing the medication. (All SP is being provided with funding from UNICEF and the Global Fund.) The policy also states that pregnant women are to be given a free ITN on their first ANC visit. Although there are no recent data on IPTp coverage, improved political stability and service coverage, as well as increased attendance at ANCs, should increase the use of IPTp in the country. Since Liberia became a PMI focus country, PMI has assisted the MOH in training 417 health workers about the risks of malaria in pregnancy, and supported demand creation for early and frequent ANC attendance through radio communications and training of community health workers.

Diagnosis and Treatment The NMCP is in the process of updating its national Note: In addition to FY08 funding, $2.5 million of FY07 funds were also used: $1,050,000 for ITNs; $50,000 for malaria in policy guidelines for malaria diagnosis. Rapid diagnostic pregnancy activities; $200,000 for diagnosis and treatment activi- tests (RDTs) have been the primary means of malaria ties; and $1,200,000 for other malaria activities, including staffing diagnosis. Liberia changed its national malaria treatment costs for USAID/CDC advisors and building in-countr y capacity policy and adopted artemisinin-based combination ther- in information management. apy (ACT) in May 2003. Since program inception, PMI:

Health and Social Welfare (MOH), along with non- • Procured an emergency consignment of 496,000 ACT governmental and faith-based organizations treatments during 2007 and distributed them to (NGOs/FBOs), have been providing high-risk groups health facilities during 2008. This procurement was in with free insecticide-treated nets with Global Fund response to a stockout of ACTs that occurred at the support. Since its launch in Liberia, PMI has procured end of a Global Fund grant that had been covering 197,000 long-lasting ITNs (using fiscal year 2007 jump the country’s ACT needs; and start funding), of which 184,000 were distributed for free during 2008. The majority of these nets (172,000) • Provided for the training of 595 health workers in were distributed as part of the door-to-door campaign malaria case management. carried out in two counties. The remaining 12,000 nets were distributed free to pregnant women through ante-

natal clinics (ANCs). TIVE

Indoor Residual Spraying (IRS) OR INITIA In the late 1950s, IRS was used as part of a malaria control effort in Liberia. During and after the conflict, the NMCP used IRS primarily as an emergency response in internally displaced persons camps. It is anticipated ARPENTIER/THE MENT that by the end of the first quarter of 2009, PMI will TSHA-C support spraying of 25,000 houses in Margibi as a first

step toward rebuilding capacity for routine IRS in Liberia. BENOIST MA An IRS trainer in Liberia presents information on the proper handling and use of chemicals during the spray campaign. Local Malaria in Pregnancy residents are recruited and trained to carry out and supervise the The NMCP’s Strategic Plan promotes prompt and effec- spray operations tive treatment of malaria in pregnant women and the use

61 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Reaching Vulnerable Women and Children in Liberia

Fatuma Sultan Koletima is a 30-year-old woman who lives in a small rural village in Ca pe Mount County. She is just one of many who have benefited from PMI’s support in Liberia. During the last rainy season, Fatuma’s children experienced many episodes of malaria and, despite visits to the traditional healer and self-medication with chlor o- quine, she and her children did not get well. Finally, Fatuma visited a health facility and was giv en ACTs that cured her children. And, because she was pregnant, Fatuma received a

dose of sulfadoxine-pyrimethamine and a new long-lasting KINSON/USAID ITN, which was provided by PMI. Fatuma reported that KARIE AT her family has been malaria free, and she is looking for- A woman holds a dose of SP, which consists of three pills, for ward to a smooth and healthy pregnancy. IPTp. Pregnant women should receive two doses of SP at least one month apart during the second and third trimesters of their pregnancies.

Monitoring and Evaluation • A lack of qualified health staff is a major challenge to In Year 1, PMI funded a Roll Back Malaria Monitoring malaria control efforts in Liberia. PMI will provide and Evaluation Systems Strengthening Tool workshop to opportunities for senior staff to receive long-term help the NMCP and key partners develop a costed, training in program management and monitoring and national malaria monitoring and evaluation plan. PMI evaluation. PMI also will support training of techni- also funded a nationwide Malaria Indicator Survey to cians in malaria laboratory diagnosis. gather baseline data for all the major malaria prevention and treatment interventions. Preliminary results of this survey are expected in mid-2009.

Challenges and Future Directions TIVE PMI and other donors have identified several key areas that will be targeted for support in the coming years to OR INITIA reduce the impact and burden of malaria in Liberia.

• Logistics systems for storage and distribution of commodities are extremely weak. PMI will work closely ARPENTIER/THE MENT

with the NMCP and other partners to improve these TSHA-C systems by renovating existing storage depots in the

capital, Monrovia, as well as at the regional and coun- BENOIST MA ty levels, and by strengthening commodity forecasting The proper way to hang a net is demonstrated during an ITN campaign in Liberia. PMI is working with its partners to increase at all levels. demand for and proper usage of long-lasting ITNs.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 62 CHAPTER 9

"This is a tremendous opportunity to scale up proven interventions to reduce the burden of malaria in Madagascar. Preventing this deadly disease will improve life, reduce costs related to illness, boost productivity and most importantly, save countless lives.” – U.S. Ambassador James D. McGee, Antananarivo, Madagascar, commenting when Madagascar became a PMI country, December 16, 2006

GENE DAILEY/AMERICAN RED CROSS/ Children proudly display an ITN their family received during Madagascar’s national measles and malaria VOICES FOR A MALARIA-FREE FUTURE campaign, which PMI supported. Net recipients learn how to hang and care for their nets as well as the importance of sleeping under a net every night.

63 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov MADAGASCAR

Malaria in Madagascar Malaria is responsible for about 16 percent of all outpatient visits and 20 percent of hospital admissions in children under five years of age, according to 2007 Ministry of Health (MOH) statistics. It is ranked as a leading cause of under-five mortality in the country. Malaria transmission rates vary across Madagascar, with higher levels of transmission on both the east and west coasts and lower transmission in the highlands and the south.

Insecticide-Treated Nets (ITNs) Madagascar supports universal coverage with long-lasting ITNs (two nets per household) in all regions of the country except in the Central Highlands, where malaria transmission is low and unstable. There is relatively high community awareness and demand for ITNs in Madagascar. Long-lasting ITNs are distributed for free

MADAGASCAR AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Provided $1 million to support Pregnant women who slept 2 Pending logistics, IEC/BCC, and a post- under an ITN the previous night 351,900 ITNs procured campaign evaluation associated Children under five who slept and distributed Pending2 with the distribution of under an ITN the previous night 1,810,000 ITNs 205,383 houses sprayed and 1,241,344 people protected (February/March 2008) Houses in geographic areas target- Not – ed for IRS that were sprayed available3 216,749 houses sprayed and 1,319,690 people protected (November/ December 2008) Women who completed a preg- Developed training materials nancy in the last two years and and tools and a quality assur- Pending2 – who received two or more doses ance system for implementing of IPTp during that pregnancy malaria in pregnancy activities Supported community-based manage- Children under five with ment of fever with a new ACT suspected malaria who received Pending2 – co-blister pack formulation ACT treatment within 24 hours of onset of symptoms Assisted in developing national guidelines on community case management BUDGET: $5 million (FY07 jump start funds) and $16.8 million (FY08) 1 PMI measured jump start and Year 1 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. The table includes USG-funded malaria jump start activities that took place in 2007 (reported in PMI’s Second Annual Report) and PMI 2008 activities. 2 Baseline coverage data will be provided by the 2008 Demographic and Health Survey, which is currently being carried out. 3 In January–March 2007, the Government of Madagascar sprayed selected communes in Fianarantsoa Province. The campaign treated 64,336 structures, protecting 409,231 inhabitants.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 64 FIGURE 9.1 that in endemic areas, 71 percent of houses had at least Allocation of $16.8 Million one long-lasting ITN, and 62 percent of pregnant PMI Budget in Madagascar, FY08 women and 75 percent of children under five had slept (Proportion of budget spent on commodities: 43%) under a long-lasting ITN the previous night. PMI also:

• Procured and distributed 351,900 long-lasting ITNs through ANC and EPI clinics for free or at highly subsidized prices through community health workers and rural shops; and

• Promoted long-lasting ITN ownership and use through mass media, mobile units, printed materials, and local entertainers.

Indoor Residual Spraying (IRS) Until it was discontinued in 1970, IRS was an important control measure in epidemic-prone areas of the Central Highlands of Madagascar. A resurgence of malaria between 1985 and 1988 prompted the re-introduction of IRS in 1989. Until 2008, IRS was applied selectively Note: In addition to FY08 funding, $5 million of FY07 funds in the Central Highlands, targeting at-risk areas. The were also used: $2,462,500 for ITNs; $1,012,500 for IRS; revised National Malaria Strategic Plan calls for an $12,500 for malaria in pregnancy activities; $478,500 for diagnosis and treatment activities; and $1,034,000 for other malaria expansion of IRS activities to reach 95 percent of activities, including community-based treatment of malaria in approximately 1.4 million dwellings in 32 health districts children under five, behavior change communication activities to protect an estimated population of 7 million in 2008 for ITN hang-up, and an environmental assessment and detailed plan for safe storage, use, and disposal of insecticide. and 2009. Since the start of PMI in Madagascar, PMI has funded through campaigns and antenatal clinics (ANCs) and two spraying campaigns: Expanded Program on Immunization (EPI) clinics, and at highly subsidized prices through volunteer community health agents and commercial outlets.

Since the start of activities in Madagascar, PMI contributed $1 million to a national integrated measles/malaria campaign in October 2007 for logistics; information, education, and communication (IEC) and behavior change communication (BCC); and postcampaign evaluation of net ownership and use. The campaign distributed a total

of 1,810,000 long-lasting ITNs, together with measles ARGASC vaccinations, deworming medication, vitamin A, and other health interventions during the national mother and child health week. The National Malaria Control Program (NMCP) and the National Expanded Program ASTEUR MADA

of Immunization conducted the campaign in partnership INSTITUT P with the World Health Organization; UNICEF; the Community-based health workers in Madagascar play a key role World Bank; the American, Canadian and Malagasy Red in the country’s efforts to combat malaria. With funding from Cross Societies; and Malaria No More. As part of the PMI and technical support from Institut Pasteur Madagascar, this team of community health workers participated in a pilot overall campaign, Malagasy Red Cross community vol- study on community-based ACT distribution in Manakara, unteers worked to increase knowledge about correct net Madagascar. hanging and usage. The postcampaign evaluation showed

65 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Combating Malaria While Safeguarding Madagascar’s Unique Environment

Madagascar, the world’s fourth largest island, is home to a great number of unique plants and animals. The island also faces high rates of malaria, and its elimination is one of the government’s major goals. Protecting this unique environment during IRS programs is of prime impor tance to the country and has been the focus of PMI-supported IRS in Madagascar. During a postcampaign environmental assessment visit following the first round of PMI-supported spraying in Madagascar, the USAID Regional Environmental Officer found weaknesses in the existing system for storage of pesticides, disposal of used insecticide sachets, and the release of pesticide residue in the environment. In response, PMI worked closely with representatives from ARGASC both the NMCP and the National En vironment Office to implement new environmental measures, including in-depth training of individuals in the safe handling of insecticides, preparation of improved storage facilities in environmentally sound sites, introduction of progressive rinsing of spray pumps, digging of soak pits for proper disposal of

rinse water, and improved control of solid waste. DONALD DICKERSON/USAID MADA Vololona Rafidiarimanana prepares her home for spraying. She On a supervisory visit during the latest campaign, the was happy to see the spray teams come to her house in USAID Regional Environmental Officer remarked on his Ambohimandroso, Ambatomaniona. “The last time the spray- “sense of satisfaction” with the implementation of the ing was done was two years ago, and I noticed the difference spraying operations, which showed a “vast improvement in the number of people getting sick from malaria.” from previous campaigns,” in terms of the practices adopted for the safe management and oversight of pesticides. PMI’s close collaboration with the NMCP and other par t- ners will help to ensure that the newly instituted environmental compliance measures are practiced throughout the country’s IRS campaign, including in those districts supported by the Global Fund. This will result in reduced health risks to sprayers and will help protect Madagascar’s unique environment. These environmental

measures also will help the countr y adopt other types of ARGASC insecticides as needed to ensure ongoing, effective coverage against mosquitoes, and ultimately protect the people who live there. DONALD DICKERSON/USAID MADA Spray operators practice progressive rinsing of their pumps to minimize quantities of contaminated rinse water in Masakalina, Anjozorobe, Madagascar.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 66 gain community acceptance and cooperation with spray teams.

Malaria in Pregnancy In June 2004, the MOH adopted the strategy of providing two doses of directly observed sulfadoxine pyrimethamine (SP) treatments free of charge to pregnant women for the prevention of malaria during pregnancy in 91 coastal and lowland districts with moderate- to high-level malaria transmission. Although antenatal clinic attendance in Madagascar is relatively high, with 80 percent of women making one or more visits during their pregnancy, uptake of intermittent preventive treatment for pregnant women (IPTp) with SP remains low, at 50 percent for MEAGHAN O'KEEFE/USAID MEAGHAN In a rural clinic in Mahajanga, Madagascar, a health care worker the first dose and only 36 percent for the second dose. prepares to test a young woman for malaria. The NMCP sup- Since activities began in Madagascar, PMI strengthened ports malaria diagnosis with RDTs or microscopy. implementation of IPTp as part of antenatal clinic services by developing training materials and tools and a quality assurance approach to implementing malaria in February/March 2008: pregnancy activities at health facilities. • Supported spraying of 205,383 houses with a synthetic pyrethroid insecticide in selected communes in Diagnosis and Treatment 24 districts in the Central Highlands, protecting In 2005, Madagascar adopted artesunate/amodiaquine 1.24 million people; 94 percent of houses targeted (AS/AQ), an artemisinin-based combination therapy for spraying were sprayed during this focalized spray- (ACT), as its first-line treatment for uncomplicated ing campaign. malaria. With PMI support, the MOH launched and began using AS/AQ co-blister packs at the community • Provided funding to train 677 local residents to con- level for the presumptive treatment of uncomplicated duct spraying and supervise operations; and malaria among children under five with a fever. At health facilities, the NMCP continues to support malaria diag- • Supported community education campaigns in all nosis with rapid diagnostic tests (RDTs) or by areas targeted for IRS, including radio spots in three microscopy. PMI has: local languages, pamphlets, and house-to-house visits by 2,032 community mobilizers and their supervisors • Conducted an assessment of nine health facility labo- to gain community acceptance and cooperation with ratories with microscopy capacity to inform future spray teams. training needs and to guide the development of a quality assurance/quality control system; November/December 2008: • Supported spraying of 216,749 houses with insecticide • Provided technical support and trained 24 people in in all communes in six districts in the Central supply chain management to strengthen the pharma- Highlands, protecting 1.32 million people; 95 percent ceutical and commodity management system; of houses targeted for spraying were sprayed; • Provided technical assistance and training to 300 • Provided funding for training 996 local residents to health professionals to enhance pharmacovigilance conduct spraying and supervise operations (including, monitoring; and for the first time in Madagascar, female sprayers); and • Strengthened drug quality control through the sup- • Supported community education campaigns in all port and expansion of minilab sentinel sites, where areas targeted for IRS, including radio spots in local drug quality can be monitored. languages, pamphlets, and house-to-house visits by 2,162 community mobilizers and their supervisors to

67 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Monitoring and Evaluation To obtain information on coverage of malaria interventions and provide a baseline for PMI in Madagascar, PMI contributed to the planning and implementation of the national 2008–2009 Demographic and Health Survey. In 2008, PMI began supporting 13 fever sentinel sites to collect data on confirmed malaria cases. These sites provide important epidemiological information on the proportion of fevers seen in outpatient clinics that are confirmed malaria cases.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 68 CHAPTER 10

“The integrated campaign was a rewarding experience for Mali, with simultaneous delivery of five life-saving interventions to roughly 2.8 million children, with an aim to drop infant and child mortality and morbidity caused by polio, malaria, and measles. Partnership was key to the successful delivery of these interventions…. Any future campaigns will benefit from the lessons learned.” – Professor Toumani Sidibe, National Director of Health for Mali, April 25, 2008

USAID Villagers celebrate at the launch of the net campaign in Mali, which is one of the new eight focus countries benefiting from PMI funding.

69 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov MALI

Malaria in Mali Malaria is one of the major causes of morbidity and mortality in Mali. In 2006, health facilities reported more than 1 million clinical cases of malaria, accounting for 41 percent of outpatient visits and more than 50 percent of deaths in children under five years of age.

Insecticide-Treated Nets (ITNs) Since 2006, the Ministry of Health (MOH) has supported free distribution of long-lasting ITNs to pregnant women during their first antenatal care visit and to children under five years with completed vaccination cards. During 2007, assisted by PMI, Mali focused on scaling up nationwide long-lasting ITN distribution through campaigns, which resulted in a substantial increase in long-lasting ITN ownership and use. A postcampaign follow-up survey conducted in August 2008 showed 74 percent use among pregnant women and 78 percent use

MALI AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Pregnant women who slept 29%2 under an ITN the previous night 858,060 ITNs procured 369,800 ITNs procured (258,060 distributed) Children under five who slept and distributed 27%2 42,522 ITNs re-treated with insecticides under an ITN the previous night

Houses in geographic areas target- No areas 107,638 houses sprayed – ed for IRS that were sprayed targeted3 and 420,580 people protected

Women who completed a preg- 1 million SP treatments procured nancy in the last two years and 4%2 – who received two or more doses 142 health workers trained in FANC, of IPTp during that pregnancy including IPTp

Children under five with ACT 101 health workers trained in ACT use suspected malaria who received implementation – ACT treatment within 24 hours began in June 40 laboratory technicians trained in of onset of symptoms 2007 malaria diagnostics

BUDGET: $4.5 million (FY07 jump start funds) and $14.8 million (FY08)

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 70 FIGURE 10.1 • Supported the treatment with insecticide of 42,522 Allocation of $14.8 Million mosquito nets that had been procured by families PMI Budget in Mali, FY08 through the private sector. (Proportion of budget spent on commodities: 40%) Indoor Residual Spraying (IRS) The National Malaria Control Program (NMCP) supports IRS as part of an integrated vector control strategy. Before PMI began in December 2006, no large-scale IRS was being carried out in Mali; since then, IRS has gained high visibility and interest. PMI supports IRS in two districts in areas of seasonal malaria transmission. In 2008, in support of the national strategy, PMI:

• Provided technical support and financial resources for the NMCP to spray 107,638 houses during July–August 2008 in two districts (Bla and Koulikoro), which protected 420,580 residents. This represents 90 percent of all houses targeted for spraying;

Note: In addition to FY08 funding, $4.5 million of FY07 funds • Supported training of 413 spray personnel and super- were also used: $3.25 million for ITNs; $400,000 for malaria in visors in IRS; and pregnancy activities; $180,000 for diagnosis and treatment activities; and $670,000 for other malaria activities, including BCC activities, dissemination of national policies and guidelines, and • Supported training for 1,848 community health workers pilot studies of community-based ACT treatment. to promote the value of IRS for malaria control and encourage cooperation with the spray teams through group meetings and house-to-house visits. among children under five compared with 29 percent and 27 percent, respectively, in 2006. Since beginning Malaria in Pregnancy activities in Mali, PMI has: Attendance at antenatal clinics (ANCs) and coverage of intermittent preventive treatment for pregnant women • Procured and supported the distribution of 369,800 (IPTp) are still low in Mali, although IPTp has been a long-lasting ITNs (as part of 2007 PMI jump start national policy since 2005. In 2006, the MOH activities). This included 200,000 nets provided to a announced that sulfadoxine-pyrimethamine (SP) for IPTp subnational campaign in June–July 2007 and an addi- would be provided free during ANC visits. Since Mali tional 169,800 nets to an integrated campaign in became a PMI country in December 2006, PMI has: December 2007, during which nearly 2.3 million free long-lasting ITNs were distributed to children under • Procured 1 million SP treatments to fill the national five in all regions, except Tombouctou and Gao, gap and worked with UNICEF to quantify additional which were covered in the subnational campaign earli- unmet needs for IPTp; er in the year. This Malian campaign was supported jointly by PMI, the World Health Organization • Funded training for 142 health workers in the new (WHO), the Canadian Red Cross, the United Nations in-service training module for comprehensive antenatal Foundation, UNICEF, Malaria No More, the Global care and supported supervision of facility staff during Fund, and nongovernmental organizations; the national scale-up of IPTp; and

• Procured 858,060 long-lasting ITNs in 2008, of • Supported a review of knowledge and perceptions which 258,060 have been distributed to health facili- related to malaria in pregnancy in Mali, which was ties to support routine Expanded Program on used to create culturally appropriate behavior change Immunization and antenatal care services; and communication (BCC) messages to increase women’s awareness of risks of malaria during pregnancy and promote attendance at ANCs and use of IPTp.

71 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Mali’s National Integrated Health Campaign

In December 2007, under the leadership of the MOH, Mali implemented its largest-ever national health campaign. This campaign delivered five health interventions: long- lasting ITNs, polio and measles vaccines for children under five, vitamin A supplements, and albendazole for deworming, to mothers and children under five, as applicable. The campaign was a joint effort among PMI (using jump star t funds), the Canadian Red Cross, the United Nations Foundation, Malaria No More, WHO, UNICEF, and many other international and local organizations. Nearly 2.3 million free long-lasting ITNs were distributed to children under five in all regions, except Tombouctou and Gao, which were covered in a subnational campaign earlier in the year. PMI contributed 169,800 nets to the campaign. The benefits of integration were numerous. Combining several interventions into one national effort enabled the Malian government and partners to reduce overall costs. The integrated campaign also made it possible f or the MOH to consolidate its efforts on information and to target the specific populations of the campaign, train personnel, and implement the interventions effectively. Moreover, the promise of free ITNs provided by PMI and CHRIS THOMAS/USAID other partners helped mobilize the local population, as This Malian child received a long-lasting ITN during the December 2007 integrated national campaign. these nets are highly valued but are often too expensive for families to purchase. A postcampaign follow-up survey conducted in August 2008 to measure coverage showed 74 percent use among pregnant women and 78 percent use among children under five compared with 29 percent and 27 percent, respectively, in 2006. The campaign is an example of how broad partnerships with the local and international comm unity can successfully integrate health services. Story submitted by Peace Corps Volunteer Ariel Wagner

Diagnosis and Treatment • Supported training for 101 health workers in malaria In Mali, PMI supports the improvement of malaria case management and supported the NMCP to carry diagnosis by microscopy through increased training, out supervision activities. supervision, and quality control. PMI also supports the NMCP’s goal of ensuring prompt, effective, and safe Monitoring and Evaluation artemisinin-based combination therapy (ACT) treatment The NMCP, with support from PMI and other partners, for 85 percent of children under five with confirmed or developed an integrated national malaria monitoring and suspected malaria. Since 2006, ACTs have been provided evaluation plan based on the findings of a Roll Back for free to children under five. Since beginning activities Malaria Monitoring and Evaluation System in Mali, PMI: Strengthening Tool workshop. During Year 1, PMI also supported five sentinel sites in health facilities, which • Worked with the MOH to conduct a needs assess- will collect routine information on laboratory-confirmed ment to identify existing gaps in malaria laboratory malaria illnesses and deaths. diagnostic capabilities and supported training of 40 laboratory technicians in malaria microscopy and use of rapid diagnostic tests; and

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 72 CHAPTER 11

“Zambia has demonstrated that malaria can be prevented, controlled, efforts sustained, and the disease eliminated, no matter how poor or remote the population.” – Honorable Brigadier-General Dr. Brian Chituwo, Minister of Health, Zambia, May 19, 2008

ARTURO SANABRIA/JSI ZAMBIA PMI is working to save lives, like this child in Zambia, who was diagnosed using a rapid diagnostic test and then treated with an ACT provided by PMI.

73 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov ZAMBIA

Malaria in Zambia Zambia has a population of approximately 12 million people, essentially all of whom are at risk of malaria. During the last three to four years, Zambia has made significant progress in malaria control with nationwide scale-up of insecticide-treated nets (ITNs), indoor residual spraying (IRS), artemisinin-based combination therapies (ACTs), and intermittent preventive treatment for pregnant women (IPTp).

Insecticide-Treated Nets Zambia has a multipronged approach to ITN distribution, including regional mass campaigns to distribute free long-lasting ITNs; provision of free long-lasting ITNs to pregnant women and children under five through antenatal clinics (ANCs); an equity program to provide free long-lasting ITNs to vulnerable populations, such as people living with HIV/AIDS and the poorest of the

ZAMBIA AT A GLANCE Baseline PMI Jump Start Results Year 1 Indicator Coverage (2007)1 (2008)1 Pregnant women who slept 24%2 under an ITN the previous night 808,332 ITNs procured 186,550 ITNs procured Children under five who slept (550,017 distributed) and distributed 23%2 under an ITN the previous night 657,695 houses sprayed Houses in geographic areas target- 762,479 houses sprayed Not available3 and 3.6 million people ed for IRS that were sprayed and 4.2 million people protected protected4

Women who completed a preg- Conducted an assessment in two nancy in the last two years and provinces to determine how best to 61%2 – who received two or more doses improve uptake of IPTp and FANC of IPTp during that pregnancy services

Children under five with 660,000 RDTs procured suspected malaria who received (979,000 RDTs distributed) 13%2 979,000 RDTs procured ACT treatment within 24 hours 253,800 ACT treatments procured of onset of symptoms 186 health workers trained in ACT use BUDGET: $9.5 million (FY07 jump start funds) and $14.8 million (FY08)

1 PMI measured jump start and Year 1 results in terms of process indicators. Results reported in this table are up-to-date as of January 1, 2009. The table includes USG-funded malaria jump start activities that took place in 2007 (reported in PMI’s Second Annual Report) and PMI 2008 activities. 2 Source: 2006 Zambia Malaria Indicator Survey. 3 Zambia’s national IRS strategy is to prioritize spraying for urban and peri-urban areas in 36 of the country’s 72 districts. At baseline, 592,346 houses were sprayed (Source: National Malaria Control Center). 4 PMI’s Second Annual Report incorrectly reported that two rounds of IRS were conducted during 2007.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 74 FIGURE 11.1 change communication (BCC) campaigns to increase Allocation of $14.8 Million demand for, and correct usage of, ITNs. PMI Budget in Zambia, FY08 (Proportion of budget spent on commodities: 44%) Indoor Residual Spraying The national strategy is to prioritize IRS to urban and peri-urban areas in 36 of the country’s 72 districts. The MOH and NMCP have the responsibility for coordinating and managing the IRS program nationally, while District Health Management Teams are responsible for local implementation.

Since Zambia became a focus country, PMI supported:

• The national IRS program by spraying 657,695 houses in 15 districts and protecting 3.6 million residents during 2007. Ninety-four percent of the houses targeted for spraying were sprayed, and a total 1,300 local residents were trained to conduct and supervise spray operations; and

Note: In addition to FY08 funding, $9.47 million of FY07 funds • The spraying of 762,479 houses (95 percent of those were also used: $3,119,884 for ITNs; $3,521,378 for IRS; targeted), which protected 4.2 million people in 2008. $1,414,362 for malaria in pregnancy activities; $541,361 for diagnosis and treatment activities; and $873,000 for other malaria A total of 1,413 local residents were trained as spray activities, including technical and financial support for the 2008 operators and supervisors. Malaria Indicator Survey, refurbishment of an insectary at the NMCP, and production and dissemination of IEC/BCC materials. PMI’s support for these campaigns has included procuring insecticides and equipment, assessing the precampaign environment, monitoring and evaluation, and ensuring poor; and the sale of ITNs through the commercial sec- appropriate insecticide storage and waste disposal. The tor. The goal of the Ministry of Health (MOH) and the high IRS coverage rates reflect the interest of local com- National Malaria Control Program (NMCP) is for all munities in IRS and the intense IEC/BCC activities households to have three long-lasting ITNs. Household undertaken in each community. ownership of at least one ITN is already relatively high in Zambia, at 60 percent, and usage rates are improving. The 2008 Zambia Malaria Indicator Survey showed that 43 percent of pregnant women and 41 percent of children under five had slept under an ITN the previous night.

Since Zambia became a PMI focus country in December 2006, PMI (including both PMI jump start activities in 2007 and PMI activities in 2008), has:

• Procured 994,882 long-lasting ITNs, of which 550,017 were distributed as part of a national campaign (PMI 2007 jump start activities), 78,315 for a campaign in North Western Province, and 108,235 TURO SANABRIA/JSI ZAMBIA TURO

through ANCs; and AR PMI’s support in Zambia includes supplying RDTs, such as these • Supported national and community-based information, being stacked here. As malaria transmission is reduced, Zambia is transitioning from malaria treatment based largely on clinical education, and communication (IEC) and behavior symptoms to diagnoses based on laboratory testing.

75 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Nationwide household surveys conducted in Zambia in an assessment in those two provinces to determine how 2006 and 2008 show that malaria control efforts, includ- best to improve uptake of IPTp and FANC services. ing both IRS and distribution of ITNs, supported by Findings from this assessment showed that the major PMI, the Global Fund, Malaria Control and Evaluation reason for failing to provide IPTp and FANC services Partnership in Africa, World Bank, and other partners, was a lack of drugs and other supplies. PMI currently is together with a strong NMCP, are already having a dra- working with the Zambia MOH to address these barriers matic impact on the prevalence of malaria and anemia to achieving improved coverage with IPTp and FANC. (Box 1). Diagnosis and Treatment Malaria in Pregnancy With the reductions in malaria transmission, Zambia is IPTp was introduced as policy in Zambia in 2003 and transitioning from malaria diagnosis based largely on became standard practice in 2004. The MOH’s clinical symptoms to laboratory confirmation with Reproductive Health Services unit incorporates IPTp microscopy or a rapid diagnostic test (RDT). PMI has into the national strategy of focused antenatal care been working closely with the MOH and NMCP to (FANC), an integrated package of preventive measures expand the quality and availability of malaria diagnostic to promote healthy pregnancies; however, rollout of this services. Since program inception, PMI has: strategy has been underfunded. Despite the fact that 61 percent of pregnant women nationwide receive two or • Procured a total of 1,639,000 RDTs (979,000 in 2007 more doses of IPTp, the 2008 Malaria Indicator Survey and 660,000 in 2008), of which 979,000 have been showed gaps in two-dose IPTp coverage among poorer distributed to health facilities; the remaining 660,000 women and those living in rural areas, especially in arrived in country in early 2009; Central and Eastern Provinces. In 2008, PMI conducted

Malaria on the Retreat in Zambia: Community Sees Results from Indoor Residual Spraying

Eunice Mwachilele of Kanyama compound in Lusaka heard about the IRS campaign from community workers who went door-to-door informing and motivating residents to OGRAM support the spraying program. After she agreed to participate, her house was marked with a sticker signaling her consent. Some weeks later, a vehicle with loud speakers AND SYSTEMS PR plied the narrow streets, informing residents to prepare VICES

for the spraying. “They told us to remove our household TH SER goods and food from the house and move our beds to the center of the room to allow spraying of the walls,” said

Eunice. “We followed their instructions. They sprayed, and A OJERMARK/HEAL we remained outside for the given time before re-entering the house.” AND MELIND Eunice and her family are among the estimated 3.6 million

beneficiaries of the IRS program that PMI supported in 15 LIZZIE PEME densely populated districts of Zambia in late 2007. After Eunice Mwachilele (left, rear), her children, and her depend- her four-room cinderblock house was sprayed in ents in Kanyama benefited from a PMI-supported IRS December 2007, Eunice commented, “We noticed since campaign. “I am very happy because we sleep freely with no that day that any mosquito that lands on the wall dies.” mosquitoes in the house. I have nothing to fear.” Neither Eunice, her four children, nor her five depend- ents have suffered from malaria since the spraying. Eunice, who is also a community health worker, noted that even with unusually high rainfall during the 2007–2008 season, many fewer malaria cases occurred in her area than in the years before the spraying program began.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 76 BOX 1 Decline in Malaria Prevalence, Severe Anemia, and Under Five Mortality in Zambia

Nationwide household surveys conducted in Zambia in 2006 and 2008 show that malaria control efforts supported by the U.S. Government (USG), the Global Fund, World Bank, the Bill and Melinda Gates F oundation, and other partners, together with a strong NMCP, are having a dramatic impact on the prevalence of malaria and anemia. Between 2006 and 2008, malaria prevalence declined by 53 percent, and the prevalence of severe anemia, which is closely associated with malaria, declined by 68 percent in children under five years old. In addition, a 2007 nationwide Demographic and Health Survey showed a 29 percent reduction in all-cause mortality in children under five, to which malaria is a major contributor. The USG has been supporting the Zambian National Malaria Control Program since 2002, including $7.6 million in FY 2006 and $9.5 million in PMI jump star t funding in FY 2007.

• Purchased 253,800 ACT treatments that have arrived in country; and

• Supported training 186 health workers in case management with ACTs.

Monitoring and Evaluation The MOH and NMCP and other partners have developed a National Malaria Prevention and Control Monitoring and Evaluation Plan for 2006–2011, which establishes clear goals, objectives, and indicators for program monitoring and evaluation. To date, PMI also is supporting the strengthening of sentinel sites for malaria surveillance in ten districts that will provide regular facility-based

data on the burden of malaria. RAPIDS Workers load bales of ITNs onto a truck in Zambia. ITNs procured by PMI were distributed free through national campaigns and at antenatal clinics.

77 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 78 CHAPTER 12

“We want to strengthen the ability of faith-based and community organizations to fight malaria while also building local ownership. Groups with local connections that have worked to build trust and provide hope are key partners in the effort to combat malaria at the local level.” – Rear Admiral R. T. Ziemer USN (Ret.), U.S. Global Malaria Coordinator, October 5, 2007, at the announcement of the first Malaria Communities Program grantees

USAID A team of well-protected sprayers prepares for a round of indoor residual spraying in the sprayers’ community in Zambézia Province, Mozambique. PMI supports programs that equip people with the knowledge and skills to help their communities fight malaria.

79 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov SUPPORTING INTERVENTIONS AT THE COMMUNITY LEVEL

Community-level interventions are core components of lasting ITNs procured by PMI were distributed for PMI’s strategy to expand malaria prevention and treat- free to pregnant women and children under five. ment measures to 85 percent of vulnerable populations in the 15 focus countries. At the community level, PMI • In Rwanda, PMI helped a local FBO train 100 religious supports communication and social mobilization, as well leaders from Christian and Muslim faith-based groups as prevention, care, and treatment activities. PMI’s sup- regarding the importance of focused antenatal care port is frequently provided through nongovernmental, and prevention of malaria during pregnancy. As a faith-based, and community-based organizations result of the training and a series of malaria work- (NGOs, FBOs, and CBOs) because of their strong bases shops, these religious leaders now include malaria of operation in peripheral areas. Through support to prevention and control messages in their sermons. these groups, PMI builds local capacity and program sustainability. Moreover, by strengthening community • In Mozambique’s Zambézia Province, PMI funded the programs in underserved areas, PMI improves access to Together Against Malaria project, which is being and increases use of critical malaria services. implemented by the Inter-Religious Campaign Against Malaria in Mozambique, a consortium of 12 Collaboration with NGOs, CBOs, and FBOs major religious groups. The objective of the project is PMI collaborates with NGOs, CBOs, and FBOs to to equip faith leaders with the knowledge and skills to expand malaria activities and leverage resources. These help people in their communities fight malaria. collaborative efforts have brought long-lasting insecticide- During the first year, the project worked with partners treated nets (ITNs), antimalarial treatment, and referral to develop key malaria prevention and treatment mes- services, provided education about how to prevent and sages and training materials. More than 1,200 faith treat malaria to underserved communities. Additionally, leaders from 79 faith groups received training on PMI’s work with these organizations facilitates commu- malaria interventions and messages to share with nication, sharing of best practices, and development of their communities. Together Against Malaria is now common systems. To date, PMI has supported nearly 150 expanding its activities to two additional provinces nonprofit organizations; more than 40 of these are FBOs. in Mozambique. Collaborative examples in Year 3 include the following: Community-based Treatment • In Malawi, PMI launched an information, education, In most African countries, more than 50 percent of and communication campaign at the community level malaria patients seek malaria treatment outside the through CBOs and NGOs. Funding was provided to formal health care system. Consequently, PMI supports organizations working in six districts to encourage efforts to provide effective community-based manage- women to seek antenatal care early in their pregnancy, ment of fever to increase access to prompt and effective go for all scheduled antenatal visits, and take at least antimalarial treatment that may reduce the risk of severe two doses of sulfadoxine-pyrimethamine for intermit- malaria and improve child survival. Five PMI focus tent preventive treatment at the appropriate times countries with successful pilot programs have policies in during pregnancy. place to expand their community-based management of fever programs nationwide and have begun to integrate • In Uganda, PMI supported a virtual net facility for treatment of malaria with pneumonia and diarrhea NGOs that provides long-lasting ITNs to CBOs at no (Ethiopia, Madagascar, Rwanda, Senegal, and Uganda). cost; these organizations then distribute the nets to Nine PMI focus countries are beginning to introduce hard-to-reach populations in their catchment areas community-based management of fever and are in the and educate the recipients about how to hang and use early stages of policy development (Angola, Benin, their nets. During 2008, more than 20 CBOs used Ghana, Kenya, Liberia, Malawi, Mali, Mozambique, this facility, and, as a result, more than 123,000 long- and Zambia).

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 80 During Year 3, PMI:

• Expanded a community-based malaria treatment program in Mali to cover three new districts in Sikasso Region;

• Trained 3,669 community health workers (CHWs) in Senegal to diagnose and treat cases of uncomplicated malaria using artemisinin-based combination therapy (ACT) and to refer patients with more serious illnesses to the nearest health facility. In 2007 and 2008,

these CHWs treated more than 67,000 patients with CE/USAID ACTs; and ALLA JULIE W • Trained more than 2,700 health extension workers in A CHW (left) and an ADDO (center) talk with a representative Ethiopia on malaria case management, recognition of from CSSC in a drug dispensary in Tanzania. PMI’s Malaria Communities Program has supported CSSC’s work with CHWs acute malaria episodes, and management of malaria in and ADDOs to improve ACT dispensing practices at the com- pregnant women. munity level.

Malaria Communities Program The Malaria Communities Program builds community • The Episcopal Relief and Development in Uige and indigenous organizations’ capacities and supports Province, Angola, to build community-based malaria their efforts to combat malaria. Grantees are new to prevention programs. As part of this effort, ITN partnering with the U.S. Government and are uniquely ownership and use in the area have increased dramati- positioned to work at the community level. Through the cally. According to a recent survey, the proportion of Malaria Communities Program, PMI issued eight new households with one or more ITNs increased, from 8 grants to NGOs and FBOs to work at the community to 86 percent in less than one year. Currently, 80 level in seven African countries, representing $11 million percent of pregnant women and 72 percent of children in total funding over the next four years. During the first under five are reported to be sleeping under an ITN, year of the Malaria Communities Program, PMI supported: coverage figures that closely approach the PMI target of 85 percent; • The Christian Social Service Commission (CSSC) in Tanzania to train private drug dispensers, known as • The Lutheran World Relief and its partner, the Accredited Drug Dispensing Outlets (ADDOs), and Evangelical Lutheran Church in Tanzania, to extend CHWs – often the first points of contact for malaria malaria prevention and control activities to five under- prevention and control. In 2008, CSSC trained 192 served rural dioceses in mainland Tanzania. Through ADDOs and CHWs. ADDOs and CHWs have used these efforts, 507 church leaders were mobilized to their training to improve their health education mes- expand community outreach and education on ITN sages and rationalize drug dispensing; use, fever management, and timely and effective treatment with ACTs. In addition, 184 health professionals from 31 mission hospitals and dispensaries were trained on early and correct malaria diagnosis and treatment, intermittent preventive treatment in pregnancy, and focused antenatal care.

81 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Partnering with Churches in Rural Malawi to Prevent Malaria

Lifa Zakeyo from Matate village in Mchinji District, Malawi, has changed her behavior in preventing malaria, thanks to her neighbor Godfrey Nkhoma. Mrs. Zakeyo and many others in her community receive regular visits from Mr. Nkhoma, who has been trained to educate his neighbors about malaria prevention and treatment. He has taught them about the importance of using an ITN every night and of seeking early treatment for children with fever, and for pregnant women, taking intermittent preventive treatment. Mr. Nkhoma also shares messages about malaria at large gatherings in his area, where he uses a variety of communication techniques, including songs and drama or dance performances. Now Mrs. Zakeyo uses her mosquito net every night to protect herself and her four children from malaria: “In the past we only used our net in the rainy season when the mosquitoes keep us from sleeping well. Now we understand the importance of using a net every night of the year to prevent malaria.” Mr. Nkhoma’s training was provided by his community’s Presbyterian church with funding and suppor t from the

Christian Reformed World Relief Committee (CRWRC). WRC MALAWI

A grant from PMI’s Malaria Communities Program allows SKI/CR CRWRC to address malaria prevention and treatment through local churches, which provide access to some of

Malawi’s most remote communities. This project has PHIL GRABOW mobilized a total of 1,320 volunteers in 13 congregational Lifa Zakeyo, Matate village, Malawi, holds an ITN she areas. A representative of Mr. Nkhoma’s village expressed received through PMI. Following training on malaria prevention his appreciation of CRWRC’s work, stating, “Thank you provided by the CRWRC through a Malaria Communities Program grant, she and her family now sleep under an ITN for reaching our area with more education – we have a every night. large population and a small health center.”

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 82 CHAPTER 13

“One of the principles of the President’s Malaria Initiative is partnership…. While the most important partner is the host country, we also work with NGOs and the private sector through to the faith-based communities and other partners. So we look at partnering at every level for the President’s Malaria Initiative.” – Rear Admiral R. T. Ziemer USN (Ret.), U.S. Global Malaria Coordinator, July 1, 2008

BENOIST MATSHA-CARPENTIER To reduce the burden of malaria in the 15 focus countries, PMI works closely with its partners to implement malaria control measures, as is happening during this ITN campaign in Mali, where a Red Cross worker checks that an ITN is hung properly.

83 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov PROGRESS THROUGH PARTNERSHIPS

Partnership Successes Private Sector Contributions Partnerships are at the heart of PMI’s strategy and • In FY 2008, the ExxonMobil Foundation made a operational plans. PMI works closely with host country third $1 million donation to USAID Angola to sup- governments; other U.S. Government agencies; interna- port PMI objectives in the country. These funds are tional organizations; other bilateral, multilateral, and being used to finance international and local NGOs private donors; nongovernmental and faith-based to deliver malaria services at the district and village organizations (NGOs and FBOs); and the private sector. levels in underserved areas of Angola. Achieving the ambitious PMI coverage targets and reducing malaria deaths by half across 15 focus countries • In Malawi, Illovo Sugar Estates, a private company, can only be achieved through a coordinated approach contributed labor toward a successful PMI indoor with a broad partner base, at both the country and inter- residual spraying (IRS) campaign. national levels. Over the past three years, PMI has forged strong partnerships in all PMI focus countries. In 2008, • The AngloGold Ashanti mining company in Ghana PMI coordinated its country programs in a combined has successfully implemented IRS campaigns in the effort with many partners; some examples are outlined Obuasi District since 2005. The company assisted in the table below: PMI’s efforts to expand IRS in Ghana by helping to conduct spray operator training and community mobilization activities.

EXAMPLES OF PMI PARTNERSHIPS 2008

Country Partners Activity PMI Contribution

National integrated child PMI transported 750,000 ITNs Ghana UNICEF, World Bank vaccination/ITN campaign, with to local distribution points and 1.5 million ITNs distributed assisted with campaign planning

National net re-treatment PMI contributed 60,000 Kenya WHO, UNICEF, DfID campaign, with 3 million ITNs long-lasting replacement ITNs re-treated

Integrated health campaign in Nampula Province, with 800,000 UNICEF, American Red Cross, long-lasting ITNs distributed PMI procured and distributed Mozambique Mozambique Red Cross with measles vaccination, 720,000 long-lasting ITNs vitamin A supplements, and deworming treatments

MOH, including NMCP/Nutrition and Child PMI procured and distributed Survival Divisions, Senegalese National campaign for vitamin A 678,556 long-lasting ITNs free Red Cross and Red Crescent distribution and deworming, to young children and another Senegal Societies, International with 678,556 ITNs distributed 69,444 nets to vulnerable Federation of Red Cross, Peace in 5 of 11 regions populations as part of Corps, Christian Children’s postcampaign activities Fund Consortium

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 84 U.S. President’s Emergency Plan for AIDS Relief • In Liberia, PMI collaborated with UNICEF, the Global (PEPFAR) Fund, and the German International Development PEPFAR and PMI have seven focus countries in com- Agency in distributing 480,000 ITNs in three large mon: Ethiopia, Kenya, Mozambique, Rwanda, Tanzania, counties (172,000 nets were contributed by PMI). Uganda, and Zambia. Since both programs target pregnant women, there are programmatic reasons to combine After only a 32 percent success rate for Round 6 Global intermittent preventive treatment for pregnant women Fund malaria proposals, PMI worked with other partners (IPTp) and the distribution of insecticide-treated nets as part of the Roll Back Malaria Harmonization Working (ITNs) with services to prevent mother-to-child trans- Group to make a concerted effort to improve the quality mission of HIV/AIDS. Examples of 2008 PMI-PEPFAR of malaria proposals to the Global Fund. In Round 7, collaboration include the following: the success rate increased to 75 percent. In the most recent round (Round 8), 14 (78 percent) of the 18 coun- • In Uganda, a USAID-supported partnership has tries that received technical support from the enabled PMI to leverage additional funds for malaria Harmonization Working Group were successful in their control. Private companies contribute funds by either grant applications. This includes four PMI focus coun- matching PMI funds or by contributing funds for tries that applied for Round 8 grants: Ethiopia, Ghana, malaria control in communities around their opera- Rwanda, and Tanzania. Because of their strong perform- tions. Partnership funds from FY 2008 allowed PMI ance under existing Global Fund grants, Ghana and to enhance PMI-PEPFAR integration and support Tanzania were also successful in their Rolling delivery of long-lasting ITNs and IPTp to an estimat- Continuation Channel malaria grant. ed 12,000 pregnant women throughout 10 major companies, including large sugar and tea producers and cement and manufacturing firms;

• In Tanzania, PMI worked with PEPFAR to develop a single procurement plan to strengthen laboratories; and

• In Rwanda, PMI and PEPFAR are coordinating the procurement of long-lasting ITNs to protect people living with HIV/AIDS as well as orphans and vulnerable children. PMI is also coordinating with PEPFAR and tuberculosis programs to improve the quality of malaria diagnosis through integrated training and supervision of laboratory workers.

Multilateral Organizations In planning its activities, PMI attempts to identify and fill gaps in funding from other global partners involved in controlling malaria. In each focus country, PMI coordinates its efforts with the Global Fund, the World Bank, the World Health Organization, and UNICEF, among others. For example:

• In Ghana, PMI staff provided technical assistance in writing the successful Global Fund Round 8 proposal that includes a $110 million IRS component. This grant will scale up IRS activities to cover 40 districts, USAID GHANA and PMI, along with AngloGold Ashanti and the Sprayers practice their techniques during a PMI-supported IRS training session that took place at the AngloGold Ashanti malaria Ministry of Health (MOH), will collaborate closely control center in Obuasi District, Ghana. during implementation; and

85 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov A Public-Private Partnership Helps to Contain Malaria Outbreaks on Zanzibar

Malaria has declined to such low levels on Zanzibar that early detection and prompt reporting of malaria cases have become critical to prevent outbreaks. Using cell phones, 52 participating health facilities report weekly malaria data via a customized text messaging menu. This innovative approach has been made possible through a public-private partnership between Selcomwireless, (a Tanzanian information technology company), the Zanzibar Malaria Control Program (ZMCP), PMI, and Research Triangle Institute. The malaria data are transmitted to a secure computer server, processed, and then sent to the ZMCP pr ogram manager, district medical officers, and other MOH authorities. When I the number of weekly laboratory-confirmed malaria cases exceeds the average number of cases from the previous three-month period, representatives from the district

health management team and ZMCP visit the health facility HAFIDH MOHAMMED/RT within 24 hours. If an outbreak is confirmed, the district Using a cell phone, a health worker enters data into Zanzibar’s surveillance officer will notify the affected community and early case detection and reporting system, made possible alert all health facilities in the aff ected district. Officials will through a novel public-private partnership. Participating then make house-to-house visits to provide presumptive health facilities report the total number of outpatient visits, number of laboratory-confirmed malaria cases, and number of ACT treatment to all residents with a fever, regardless of persons tested for malaria that week. whether they have laboratory-confirmed malaria. Officials may also decide to initiate selective IRS to supplement the already high levels of ITN ownership and usage.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 86 CHAPTER 14

“The people who really make a difference in all of this are actually the health workers out in the health clinic, who work under very hard conditions. But they still manage to go on and they still manage to somehow provide the services that are necessary to save mothers and children. Those are the real heroes of this story.” – Lotta Sylwander, UNICEF Representative in Zambia, May 28, 2008

BONNIE GILLESPIE/ In rural Ethiopia, a community health worker instructs a family on the proper use of ACTs. PMI is working with VOICES FOR A MALARIA-FREE FUTURE the Ethiopian government to strengthen management of antimalarial drugs throughout the health care system.

87 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov BUILDING HEALTH SYSTEMS AND NATIONAL CAPACITY

PMI supports the sustainability of its programs by strengthening health systems and building the capacities SUSTAINABILITY – A HIGH PRIORITY FOR PMI of public and private sector health workers and managers. Sustainability is a high priority for PMI. Toward this All PMI activities directly support national malaria con- end, PMI is working to promote: trol plans and strategies and are implemented together • Increased funding by host governments for their with national Ministries of Health (MOHs). As part of national malaria programs; that approach, PMI interventions typically build on and • Increased diversification and long-term funding by support the overall health system and delivery of primary donors and partners; health care services at the country level. • Improved quality of malaria ser vices; • High and sustained national coverage rates for Pharmaceutical Management malaria prevention and treatment interventions; PMI’s support of national pharmaceutical management • Active involvement of community, nongovernmental, systems is improving not only the management of malaria and private sector organizations in malaria contr ol commodities, but also the management of all essential at all levels; and • Long-term changes in behavior (e.g., culture of drugs. In FY 2008, PMI allocated more than $8.4 million using ITNs, care-seeking behavior) among vulnera- to help build the pharmaceutical management systems of ble populations. PMI focus countries, including forecasting the needs of commodities, storing and distributing commodities, and training medical store staff and health workers in these management and reporting of consumption data, and other skills. In Kenya, for example, PMI’s support quantification, supervision, and KEMSA’s procurement for improved procurement, management, and distribution capacity not only are critical to effective delivery of of antimalarial drugs is combined with support for malaria drugs, but also contribute to the overall essential management and distribution of other health commodi- medicines delivery system. Similarly, in Zambia, PMI, ties and essential medicines through the Kenya Medical the U.S. President’s Emergency Plan for AIDS Relief, Supply Agency (KEMSA). PMI’s investments in the USAID child health and family planning programs, the strengthening of the supply chain system, inventory U.K. Department for International Development, and the World Bank are working together to improve the essential drug system in Zambia.

PMI also designed and began implementing a commodity end-use verification program to help MOHs monitor the availability and correct use of essential malaria drugs. In eight countries, PMI is helping MOHs monitor the quality of artemisinin-based combination therapies (ACTs) and other drugs. Results from the initial pilot of this tool implemented in Tanzania are already being used by the MOHs to improve distribution of antimalarials and other essential medicines.

DELIVER/JSI Health Management Information Systems Meba Kagone (center), a PMI project manager, and Gabriel Thompson (right), from the NMCP, give nets and review data PMI is working with National Malaria Control with a community health worker in Bomi County, Liberia. During Programs (NMCPs) and other partners to develop and this door-to-door campaign, which took place in February 2008, implement comprehensive national malaria monitoring 172,000 nets were distributed in two counties. PMI is working with the NMCP and other partners to improve Liberia’s system for and evaluation plans, many of which are incorporated storing and distributing commodities. within overall health information systems. As a result of these efforts, program managers at all levels are gaining

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 88 • PMI has supported ten nationwide household surveys PMI Stock Monitoring System with plans for future surveys to help countries establish baselines and track progress in their malaria control In 2008, PMI worked with two of its implementing efforts. Through support of these surveys, PMI also is partners to develop and roll out a stock monitoring building capacities within MOHs to collect, analyze, tool to track supplies of drugs and other commodities. and use data for better decision-making and planning. In the case of ACTs, the tool reports on central-level ACT stocks from all sources – PMI, the Global Fund, and other donors – and ser ves as an early warning Integrated Maternal and Child Health Services system for impending ACT stockouts or overstocks. Under PMI, malaria prevention and control activities are It is currently in use in ten countries, and additional implemented as part of integrated maternal and child countries are expected to join. The first quarterly health services and make a significant contribution to the monitoring report was issued in October 2008, and strengthened capacity to deliver these services. Insecticide- the results were used to plan the procurement of treated nets (ITNs) are distributed principally through PMI-funded ACTs. antenatal care and child health services or through integrated campaigns that include other interventions such as vitamin A supplements or measles vaccinations. Intermittent preventive treatment for pregnant women (IPTp) with sulfadoxine-pyrimethamine is a key element of antenatal care; ACTs are provided as part of child health services. Due to its unique nature, indoor residual spraying (IRS) is implemented by NMCPs and communities as a discrete intervention. PMI also supports:

• Integrated Management of Childhood Illness programs in four countries, including training and supervision of health workers in the diagnosis and treatment of common childhood illnesses and appropriate referral;

• Implementation of community-based management of fever in six countries, in which child pneumonia and

TURO SANABRIA DELIVER/JSI ZAMBIA TURO malaria are diagnosed and treated by trained community AR volunteers; and A worker reviews medicine stock cards at the Chainama Clinic in Lusaka, Zambia. Monitoring stocks of drugs is essential to avert shortages. • Focused antenatal care (FANC) programs in seven countries. FANC deals broadly with the full set of services for pregnant women during their antenatal care visits, rather than focusing on disease-specific interventions. experience and developing the capacity to collect and more effectively use data for programmatic decisions. Quality of Laboratory Services This skill is critically important for all public health With several PMI countries achieving reductions of interventions. Specifically: malaria burden, the need to accurately diagnose malaria through high-quality laboratory services is becoming • Monitoring and evaluation system strengthening even more important. Fourteen PMI countries are workshops have been completed in 14 of the 15 PMI investing in strengthening laboratory diagnostic systems, focus countries, in collaboration with the Global Fund including training and supervision of laboratory workers and the World Bank. PMI, along with partners, is and establishing quality assurance systems for helping NMCPs finalize their national malaria moni- microscopy and rapid diagnostic tests. In several coun- toring and evaluation plans and implement the key tries, PMI is also helping to support national reference recommendations from these workshops. laboratories. These efforts to upgrade laboratory services help improve the overall quality of primary health care, diagnosis, and treatment.

89 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov Building Health Workers’ Skills to Implement a New Malaria Treatment Policy in Malawi

In 2006, the Malawi MOH selected the ACT artemether- lumefantrine (AL) as its first-line drug f or the treatment of uncomplicated malaria. In November 2007, Malawi officially launched the new policy countrywide; however, one of the greatest challenges to implementation of the new policy was a lack of ca pacity among health care workers and pharmacy personnel to manage the ne w treatment, particularly its storage, rational use, and inventory control, including good record-keeping and reporting. In response to this problem, PMI provided technical support for staff training and super vision for Malawi’s NMCP and district health offices. More than 500 health workers were trained in filling out and maintaining stock car ds for AL SYSTEMS

AL, recording actual AL consumption data in the dispensing EUTIC register, and filing reports using the national logistics management information system. Bernard Jali, a medical assistant, attended this training in April 2008 in Dedza District. When he transferred to the STRENGTHENING PHARMAC Kaphuka Health Centre in early June 2008, he found that, Bernard Jali, a medical assistant in Malawi, has used the train- as with many health facilities in Malawi, it had poor phar- ing he received on pharmaceutical management to make sure maceutical management practices. For example, stock his health center is well stocked in antimalarial and other cards to record the quantity of drugs received or issued essential drugs. were either nonexistent or were not updated regularly. These practices affected the quality of information that district health officers, regional medical stores, and central medical stores receive on consumption of drugs, which they need to replenish stock at the health centers. Mr. Jali immediately applied his new knowledge to improve the management of AL. Kaphuka Health Centre now has accurate stock cards for AL, and since June 2008, the facility has submitted its AL consumption and stock-on-hand reports to the district hospital on time e very month. Through his pharmaceutical management training, Mr. Jali has been able to share his knowledge and transform the way his health facility manages AL and other essential medicines, which help ensure that the health center always has the medicines it needs.

Strengthening Health Worker Performance outpatient cases in many PMI focus countries) is expected In 2008, PMI trained more than 35,000 health workers to allow needed resources and overstretched health care on case management with ACTs, more than 1,600 in workers to concentrate on controlling other childhood malaria laboratory diagnostics, and more than 14,000 in illnesses, such as diarrhea and pneumonia. Studies are IPTp. In 11 countries, PMI also is funding the strength- currently under way to measure the increased productivity ening of integrated health worker supervision systems, of health workers when malaria rates fall. which will contribute to the effective delivery of other health interventions, in addition to malaria. Overall Capacity Building In all its activities, PMI works to develop the capacities Controlling Malaria Reduces the Burden on the of host country health workers and institutions. In 2008, Health Sector PMI developed tools to track the transfer of skills to By reducing the burden of malaria in highly-endemic national staff in the areas of IRS and pharmaceutical countries, PMI is helping to improve the functioning of management. For example, PMI is tracking 30 key host country health systems. The reductions in malaria activities that are critical for the effective planning, cases (currently, malaria accounts for 30 to 40 percent of conducting, and monitoring of IRS programs.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 90 APPENDIX 1 BASELINE AND INTERIM COVERAGE OF MALARIA INTERVENTIONS IN PMI FOCUS COUNTRIES

ROUND 1 FOCUS COUNTRIES TANZANIA Indicator ANGOLA UGANDA Mainland Zanzibar Baseline Baseline Baseline Interim Baseline Interim

Pregnant women who slept under an ITN the 22%1 10%1 16%1 26%3 20%1 51%3 previous night

Children under five who slept under an ITN the 18%1 10%1 16%1 25%3 22%1 59%3 previous night

Houses in geographic areas No areas No areas No areas No areas targeted for IRS that were N/A N/A targeted2 targeted2 targeted2 targeted2 sprayed

Women who completed a pregnancy in the last two years and who received 3%1 16%1 22%1 30%3 14%1 52%3 two or more doses of IPTp during that pregnancy

Children under five with suspected malaria who ACTs not yet ACTs not yet received ACT treatment 1.5%1 1%1 14%3 8%3 implemented1 implemented1 within 24 hours of onset of symptoms

ANGOLA: 1 2006–2007 Malaria Indicator Survey. 2 At baseline, no areas were targeted for spraying by the NMCP.

UGANDA: 1 2006 Demographic and Health Survey. 2 At baseline, no areas were targeted for spraying by the NMCP.

TANZANIA: 1 2004–2005 Demographic and Health Survey. 2 At baseline, no areas were targeted for spraying by the NMCP. 3 2007–2008 HIV/AIDS and Malaria Indicator Survey.

91 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov ROUND 2 FOCUS COUNTRIES

RWANDA Indicator MALAWI MOZAMBIQUE SENEGAL Baseline Baseline Baseline Interim Baseline Pregnant women who slept under an ITN the 15%1 7%1 17%1 62%3 17%1 previous night

Children under five who slept under an ITN the 23%2 7%1 13%1 58%3 16%1 previous night

Houses in geographic areas No areas No areas targeted for IRS that were Not available2 N/A Not available2 targeted3 targeted2 sprayed Women who completed a pregnancy in the last two years and who received 43%1 16%1 <1%1 14%3 49%1 two or more doses of IPTp during that pregnancy Children under five with suspected malaria who ACTs not yet ACTs not yet received ACT treatment 4.5%1 Pending3 3%1 implemented implemented1 within 24 hours of onset of symptoms MALAWI: 1 2004 Demographic and Health Survey. 2 2006 Multiple Indicator Cluster Survey. 3 At baseline, no areas were targeted for spraying by the NMCP.

MOZAMBIQUE: 1 2007 Malaria Indicator Survey, Preliminary Report. 2 Two large-scale IRS programs were under way in 2006, supported by the MOH and the Lubombo Spatial Development Initiative.

RWANDA: 1 2005 Demographic and Health Survey. 2 At baseline, no areas were targeted for spraying by the NMCP. 3 2008 Demographic and Health Survey, Preliminary Report.

SENEGAL: 1 2006 Malaria Indicator Survey. 2 The 2006 Malaria Indicator Survey showed that 2.2% of households nationwide had been sprayed.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 92 ROUND 3 FOCUS COUNTRIES ZAMBIA Indicator Baseline Interim

Pregnant women who slept under an ITN the pr evious night 24%1 43%3

Children under five who slept under an ITN the pr evious night 23%1 41%3

Houses in geographic areas targeted for IRS that were sprayed Not available2 N/A

Women who completed a pregnancy in the last two years and 61%1 60%3 who received two or more doses of IPTp during that pr egnancy

Children under five with suspected malaria who received 13%1 8%3 ACT treatment within 24 hours of onset of symptoms

1 2006 Malaria Indicator Survey. 2 Zambia’s national IRS strategy is to prioritize spraying for urban and peri-urban areas in 36 of the country’s 72 districts. At baseline, 592,346 houses were sprayed (Source: National Malaria Control Center). 3 2008 Malaria Indicator Survey.

93 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov APPENDIX 2 PMI COUNTRY-LEVEL TARGETS

PMI has a single set of countr y-level targets for the four major control measures. These targets are the same for each focus country, and they apply to the populations most vulnerable to malaria: children under age five and pregnant women. • More than 90% of households with a pr egnant woman and/or children under five will own at least one ITN; • 85% of children under five will have slept under an ITN the pr evious night; • 85% of pregnant women will have slept under an ITN the pr evious night; • 85% of houses in geographic areas targeted for IRS will have been sprayed; • 85% of pregnant women and children under five will have slept under an ITN the pr evious night or in a house that has been protected by IRS; • 85% of women who have completed a pregnancy in the last two years will have received two or more doses of IPTp during that pregnancy; • 85% of governmental health facilities will have ACTs available for treatment of uncomplicated malaria; and • 85% of children under five with suspected malaria will have received ACT treatment within 24 hours of onset of symptoms.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 94 APPENDIX 3 SUMMARY OF RESULTS BY INTERVENTION

INSECTICIDE-TREATED NETS (ITNs) PROCURED BY PMI AND DISTRIBUTED WITH PMI SUPPORT ITNs Procured

Country ITNs Distributed PMI Year 1 PMI Year 2 PMI Year 3 Cumulative (2006) (2007) (2008) 540,949 294,200 734,198 1,569,347 Angola 540,949 0 339,440 880,389 130,000 0 143,560 273,560 Tanzania 130,000 0 113,560 243,560 376,444 1,132,532 480,000 1,988,976 Uganda 305,305 683,777 999,894 1,988,976 – 1,039,400 849,578 1,888,978 Malawi – 211,995 849,578 1,061,573 – 786,000 720,000 1,506,000 Mozambique – 565,000 842,802 1,407,802 – 0 550,000 550,000 Rwanda – 0 0 0 – 200,000 790,000 990,000 Senegal – 196,872 792,951 989,823 – 221,0001 385,697 606,697 Benin – 215,6271 45,840 261,467 – 102,1451 22,284 124,429 Ethiopia (Oromia) – 102,1451 22,284 124,429 – 60,0231 350,000 410,023 Ghana – 60,0231 0 60,023 – – 60,000 60,000 Kenya – – 60,000 60,000 – 197,0001 0 197,000 Liberia – – 184,000 184,000 – – 351,900 351,900 Madagascar – – 351,900 351,900 – 369,8001 858,060 1,227,860 Mali – 369,8001 258,060 627,860 – 808,3321 186,550 994,882 Zambia – 550,0171 186,550 736,567 1,047,393 5,210,432 6,481,827 12,739,652 TOTAL 976,254 2,955,256 5, 046,859 8,978,369

1 2007 PMI jump start activities.

95 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov ARTEMISININ-BASED COMBINATION THERAPIES (ACTs) PROCURED BY PMI AND DISTRIBUTED WITH PMI SUPPORT ACTs Procured

Country ACTs Distributed PMI Year 1 PMI Year 2 PMI Year 3 Cumulative (2006) (2007) (2008) 587,520 2,033,200 3,035,520 5,656,240 Angola 0 1,101,801 2,985,958 4,087,759 380,160 694,050 146,730 1,220,940 Tanzania 380,160 494,050 346,730 1,220,940 261,870 0 1,140,480 1,402,350 Uganda 227,827 0 0 227,827 – 4,694,013 4,501,740 9,195,753 Malawi – 4,694,013 3,579,278 8,273,291 – 1,440,000 3,525,120 4,965,120 Mozambique – 220,230 1,440,000 1,660,230 – 715,000 0 715,000 Rwanda – 0 411,788 411,788 – 0 0 0 Senegal – 0 0 0 – 1,465,1701 0 1,465,170 Benin – 153,8841 326,544 480,428 – – 600,000 600,000 Ethiopia (Oromia) – – 0 0 – – 1,142,759 1,142,759 Ghana – – N/A 0 – – 1,281,720 1,281,720 Kenya – – 1,281,720 1,281,720 – 496,0001 0 496,000 Liberia – – 496,000 496,000 – – 0 0 Madagascar – – 0 0 – – 0 0 Mali – – 0 0 – – 253,800 253,800 Zambia – – 0 0 1,229,550 11,537,433 15,627,869 28,394,852 TOTAL 607,987 6,663,978 10,868,018 18,139,983

1 2007 PMI jump start activities.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 96 INSECTICIDE-TREATED NETS PROCURED BY OTHER PARTNERS AND DISTRIBUTED WITH PMI SUPPORT PMI Year 1 PMI Year 2 PMI Year 3 Cumulative Country (2006) (2007) (2008) Angola 0 0 109,624 109,624 Tanzania 0 0 350,000 350,000 Uganda 0 369,900 0 369,900 Mozambique – 0 78,000 78,000 Ghana – – 750,000 750,000 TOTAL 0 369,900 1,287,624 1,657,524

ARTEMISININ-BASED COMBINATION THERAPIES PROCURED BY OTHER PARTNERS AND DISTRIBUTED WITH PMI SUPPORT PMI Year 1 PMI Year 2 PMI Year 3 Cumulative Country (2006) (2007) (2008) Uganda 0 8,709,140 112,330 8,821,470 TOTAL 0 8,709,140 112,330 8,821,470

PEOPLE PROTECTED BY PMI-SUPPORTED INDOOR RESIDUAL SPRAYING

PMI Year 1 PMI Year 2 PMI Year 3 Country (2006) (2007) (2008) Angola 590,398 612,776 992,8561 Tanzania (Zanzibar) 1,018,156 1,120,3811 1,120,3811 Tanzania (Mainland) 0 159,579 448,690 Uganda 488,502 1,865,956 2,211,388 Malawi – 126,126 106,450 Mozambique – 2,593,949 1,457,142 Rwanda – 720,764 885,957 Senegal – 678,971 645,3461 Benin – – 521,738 Ethiopia (Oromia) – 3,890,0002 5,921,906 Ghana – – 601,973 Kenya – 3,459,2072 3,061,967 Liberia – – 0 Madagascar – – 2,190,9891 Mali – – 420,580 Zambia – 3,600,0002 4,200,000 TOTAL 2,097,056 18,827,709 24,787,363

1 Indoor residual spray operations typically involve successive rounds of spraying in the same geographical area. To avoid counting the same people twice, only one round is counted within any given year. 2 2007 PMI jump start activities.

97 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov HEALTH WORKERS TRAINED WITH PMI SUPPORT IN ACT USE PMI Year 1 PMI Year 2 PMI Year 3 Country (2006) (2007) (2008) Angola 1,283 290 1,357 Tanzania 4,217 1,011 1,767 Uganda 2,844 12,637 9,159 Malawi – 0 5,315 Mozambique – 174 422 Rwanda – 5,127 8,565 Senegal – 1,020 4,776 Benin – 6051 0 Ethiopia (Oromia) – – 2,786 Ghana – – 368 Kenya – – 0 Liberia – – 595 Madagascar – – 0 Mali – – 101 Zambia – – 186 TOTAL 8,344 20,864 35,397 1 2007 PMI jump start activities.

HEALTH WORKERS TRAINED WITH PMI SUPPORT IN IPTp USE PMI Year 1 PMI Year 2 PMI Year 3 Country (2006) (2007) (2008) Angola 1,450 290 1,481 Tanzania 376 1,158 4,169 Uganda 168 807 649 Malawi – 0 2,747 Mozambique – 0 0 Rwanda – 250 436 Senegal – 43 2,422 Benin – 6051 1,267 Ethiopia (Oromia) – – 0 Ghana – – 464 Kenya – – 0 Liberia – – 417 Madagascar – – 0 Mali – – 142 Zambia – – 0 TOTAL 1,994 3,153 14,194 1 2007 PMI jump start activities.

WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov 98 ACKNOWLEDGMENTS

The Third Annual Report of the President’s Malaria Initiative is dedicated to the staff of host governments, international and local partners, and all U.S. Government staff who have contributed to the achievements described in these pages.

PRESIDENT’S MALARIA INITIATIVE

99 WORKING WITH COMMUNITIES TO SAVE LIVES IN AFRICA www.pmi.gov U.S. Agency for International Development 1300 Pennsylvania Avenue, NW Washington, DC 20523 www.usaid.gov